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MEETING HEALTH CARE NEEDS: THE PERSPECTIVE OF RURAL COMMUNITYDWELLING OLDER ADULTS WITH MULTIPLE CHRONIC DISEASES DURING THE COVID-19 PANDEMIC Submitted to the Faculty of the College of Health and Sciences University of Indianapolis In partial fulfilment of the requirements for the degree Doctor of Health Science By: Romeo Acosta, PT, MHS Copyright December 9, 2021 By: Romeo Acosta, PT, MHS All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH Committee Chair ___________________________________________ Sharon Baggett, PhD Committee Member ___________________________________________ Lisa Borrero, PhD Committee Member ___________________________________________ Accepted by: Laura Santurri, PhD, MPH, CPH ___________________________________________ Director of DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ___________________________________________ RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Meeting Health Needs: The perspective of Rural Community-Dwelling Older Adults with Multiple Chronic Diseases During the COVID-19 Pandemic Romeo Acosta, PT, MHS Department of Interprofessional Health and Aging Studies, University of Indianapolis 1 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 2 Abstract Background: The majority of older adults, due to aging processes, suffer from two or more medical problems. Therefore, it was anticipated that their lived experiences would include unique challenges during the COVID-19 pandemic. Also, community-dwelling older adults in rural areas experience more significant healthcare disparities than their urban counterparts due to low socioeconomic status, insufficient healthcare workers, and lack of infrastructure. Purpose: This qualitative phenomenological study aimed to understand the lived experiences of rural community-dwelling older adults with multiple chronic diseases during the COVID-19 pandemic. Its primary focus was to determine how this population experienced health care during this time. Method: The transcribed data from semi-structured interviews were analyzed using Colaizzi's descriptive phenomenological method to extract more profound meaning, and interpretations of the participants' lived experiences. The results of this study were anticipated to inform healthcare providers, educators, and policymakers of the necessary changes in policies and planning to ensure that the healthcare needs of rural community-dwelling adults will be met in the next healthcare crisis. Results: Access to health services, lifestyle changes, the influence of technology, the impact of mitigation protocol, and health and wellbeing are the main themes that provided a better understanding of the health care experiences of rural community-dwelling older adults during the COVID-19 pandemic. Conclusions: Despite the challenges, the rural community-dwelling older adults showed resiliency, resourcefulness, perseverance, adaptation, and reliance on religious faith to overcome the barriers imposed by the COVID-19 pandemic in meeting their health care needs. Keywords: rural community-dwelling older adults, COVID-19, age-related chronic comorbidities, public health, social distancing RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 3 Acknowledgments It would not have been possible to complete this research project without several individuals and my work organization's support, cooperation, and participation. These sources of help are family members, project committee members, participants, coworkers, and a volunteer experienced in qualitative research data coding. Their contributions inspired, motivated, and sustained me to keep moving forward. I am forever indebted and grateful for their precious time and efforts. I would like to recognize my mother, who instilled a self-reliant can-do attitude, which helps me believe that anything is achievable with hard work, diligence, and perseverance. My wife, Michele, provided invaluable counsel and encouraged me to have confidence when I had self-doubt, and I greatly appreciate her patience. I strive for professional growth to be an excellent example for my daughters (Deniece Nicole and Alejandra Isabel Acosta). They are my inspirations to be a good person, keep moving forward and make a positive impact in life. This project would not have taken shape as it should without the invaluable expert and highly knowledgeable guidance from my committee chair, Dr. Laura Santurri. Her skills and experience in qualitative research helped me navigate every challenging turn along the process leading me to the right destination. Another professor who stoked my interest in qualitative studies was Dr. Lisa Borrero. As the project analysis expert of the committee, Dr. Borrero's proficiency was instrumental in helping me make sense of the copious data collected. Dr. Sharon Baggett's expertise with the participants' demographic in this study was instrumental in customizing communication most effectively. I learned essential nuances of communication through written and spoken means from Dr. Baggett that made participants comfortable and willing to share their lived experiences without hesitation. My project committee's patience in RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 4 their responses to my questions and work drafts motivated me to push forward, especially when I felt diminished and incapable. I want to give a special mention and thanks to Dr. Elizabeth Horrall Stith. I am enormously grateful for her contribution to this endeavor. Dr. Stith's input was crucial in deciphering and interpreting the meaning of the shared lived experiences of the participants of this research project, which is the goal of this project. I could not thank her enough for taking some precious time away from her family to help me. The cooperation and support of my work organization, American Nursing Care, has been crucial in choosing and recruiting participants. Thomas Drook, our branch's director of operations, welcomed my project and assisted me in reaching out to appropriate authorities for permission to conduct the research project. Mr. Drook also communicated to my coworkers the corporate approval of the project and allowed me to implore their assistance in disseminating recruitment flyers. I want to give special mention to four of my colleagues, Linda White-Lewis RN, Steve Eilerman, PT, Oliver Cordova, PT, and Karen Turner, PTA. They all put in extra effort to help me with recruiting participants. I want to acknowledge Gina Lucas, our Associate Corporate Responsibility Officer, who efficiently facilitated the research project's corporate approval. Finally, I want to extend my deep gratitude to all of the participants of this research project. All participants welcomed the intrusion of the project into their lives, even amid the COVID-19 pandemic uncertainties. The primary reason for volunteering to participate in this research project is to help others in similar healthcare situations during this pandemic. Their resiliency, resourcefulness, perseverance, adaptation, and positive outlook during this pandemic are character models for all of us to follow. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 5 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgement ...........................................................................................................................3 Chapter 1: Introduction....9 Background .9 Problem Statement 10 Purpose Statement .10 Research Question 10 Significance of Study 11 Definition of Terms ...11 Chapter 2: Literature Review ....11 The Coronavirus Disease 2019 (COVID-19) Outbreak 12 COVID-19 in the U.S. ..13 Vulnerable Populations During COVID-19 .14 Racial/Ethnic Minorities and Immigrants ....14 Individuals Experiencing Homelessness, Substance Abuse Problems, and Physical Impairments ..15 Older Adults ..16 Rural Community-Dwelling Older Adults 17 Challenges for Rural CDOA During COVID-19 Pandemic .17 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 6 Positive Role of Technology for Rural CDOA .19 Gap in the Literature .20 Chapter 3: Method ....21 Study Design .21 Participants 22 Setting ....................................................................................................................................... 23 Procedures .23 Recruitment ...23 Informed Consent.................................................................................................................. 27 Data Collection Process ........................................................................................................ 28 Data Management and Analysis ..............................................................................................................31 Rigor and Trustworthiness 33 Results ........................................................................................................................................... 36 Theme 1: Lifestyle Changes .....37 Physical Activity ............................................................37 Socialization.......................................................................................................................... 38 Shopping Habits .................................................................................................................... 41 Entertainment/Recreation ..................................................................................................... 43 Theme 2: Impact on Health and Wellbeing .............................................................................. 44 Mental/Spiritual .................................................................................................................... 44 Medical Conditions Impacted the Most ................................................................................................ 46 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 7 Outlook on Life ..................................................................................................................... 47 Coping Mechanism ............................................................................................................... 48 Theme 3: Access to Health Care Services ................................................................................ 50 Appointments ........................................................................................................................ 50 Health Care Needs, Interventions, and Treatment ............................................................................. 52 Pharmacology ....................................................................................................................... 54 Support System ..................................................................................................................... 55 Theme 4: Use of Technology.................................................................................................... 56 Health Care Purposes ............................................................................................................ 56 Personal Use.......................................................................................................................... 57 Financial Limitations ............................................................................................................ 58 Participants' Recommendations to Help Improve Access and Delivery of Health Care Services for CDOA in the Next Pandemic .............................................................................................. 59 Chapter 4: Discussion ...62 Support Systems........................................................................................................................ 65 Social Connections................................................................................................................ 65 Local Community Programs ................................................................................................. 66 Health Care System............................................................................................................... 69 Study Limitations ...................................................................................................................... 71 Implications for Future Research .............................................................................................. 72 Conclusion .................................................................................................................................... 73 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 8 References .744 Table 1 Participant Characteristics ..91 Table 2 Codebook Example ..92 Table 3 Codebook Example: Final Theme ...93 Figure 1 Colaizzis Seven Steps Coding Process......94 Figure 2 Colaizzis Desscriptive Phenomenological Analysis Methodology ...........95 Figure 3 Example of Perceived Theme Relationships ......96 Appendices 97 Appendix A IRB Approval ...97 Appendix B Letter of Cooperation .......98 Appendix C Approval of Letter of Cooperation 100 Appendix D Recruitment Flyer ...102 Appendix E Information Sheet ...103 Appendix F Interview Guide ..106 Appendix G First Member-Checking Letter of Instructions ..111 Appendix H Narrative Description of Final Themes ..112 Appendix I Second Member-Checking Instructions .......120 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 9 Meeting Health Care Needs: The Perspective of Rural Community-Dwelling Older Adults with Multiple Chronic Diseases During the COVID-19 Pandemic Before the COVID-19 pandemic, there were already existing inequities in health care access that were worsening for many groups in the United States [U.S.] (Yamada et al., 2015). The federal and state public health agencies' ineffective response to the COVID-19 pandemic brought the U.S. health care disparities to the fore of general discussions (Weible et al., 2020). The social distancing aspect of the community mitigation protocol that the Centers for Disease Control and Prevention agency implemented has negatively impacted individuals' health, financial, social, and psychological status (Douglas et al., 2020). Older adults are one of the vulnerable groups significantly impacted by the COVID-19 pandemic as most have more than one chronic disease, which increases their risk of acquiring the virus and experiencing poor outcomes (Turk & McDermott, 2020). The stay-at-home mandate has prevented community-dwelling older adults (CDOA) from getting to fitness centers, parks, community centers, churches, and family members and friends' houses, which dramatically reduced their physical activities, social interactions, and participation in health care management (Weible et al., 2020). For many CDOA, the COVID-19 social distancing protocol has exacerbated loneliness and depression and increased difficulty accessing health care services and delivery (Douglas et al., 2020; Wand et al., 2020). In rural communities, the effective management of the CDOAs health and well-being is influenced by lower socioeconomic status, insufficient health care workers, and the lack of public and private infrastructure (Bolin et al., 2015). Therefore, having fewer resources and services than the rest of the population makes meeting the health care needs of rural CDOA more challenging when access is disrupted. Accordingly, social distancing during the COVID-19 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 10 pandemic has made the lives of CDOA in rural communities even more isolated and access to food sources, community support centers, health and fitness facilities, and healthcare delivery and services more difficult (Morrow-Howell et al., 2020; Naja & Hamadeh, 2020) Problem Statement The effective management and maintenance of health and well-being in older adults depends on access to quality healthcare, including the availability of healthcare providers, communication infrastructure (internet connectivity), transportation, community services, and affordability of services (Bolin et al., 2015; Skoufalos et al., 2017). The recent global pandemic has exacerbated disparities and disrupted essential services and resources in health care for rural CDOA (Morrow-Howell et al., 2020). Studies that aim to understand the impact of these disruptions through the lived experiences of rural CDOA during the COVID-19 health crisis are currently lacking. Purpose Statement This qualitative phenomenological study aimed to understand the lived experiences of rural CDOA with multiple chronic diseases during the COVID-19 pandemic. Of specific focus was how this population experienced health care during this time. Research Questions This study attempted to address the following primary research question and associated sub-questions: How do community-dwelling older adults with multiple chronic diseases in rural midwestern town describe their health care experience during the COVID-19 pandemic? o How do rural community-dwelling older adults meet their health care needs? RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 11 o How does the social distancing aspect of the public health agencys mitigation guidelines affect the rural community-dwelling older adults access to health care services and delivery? o How do the COVID-19 pandemic influenced and affected the rural communitydwelling older adults' experiences and attitudes about using digital technologies related to health care? Significance of the Study The results of this study may help inform the development of a practical, equitable, and just public health preparedness protocol for the next global pandemic that explicitly addresses the health care needs of rural CDOA. Definition of Terms Chronic diseases: Medical conditions that are persistent and limit daily living activities requiring ongoing monitoring and treatment (Raghupathi & Raghupathi, 2018). Community-dwelling older adults: Adults 65 years and older who live independently in non-institutionalized residences. Rural community: Inhabitants, dwellings, and geographic areas outside the definition or boundaries of urban areas (50,000 individuals) and urban clusters (at least 2,500 but less than 50,000 individuals) in the U.S. (United States Census Bureau, 2010). Literature Review The world has been plagued with pandemics throughout history. In addition to the severe illness, permanent debility, and death that pandemics can cause, they can also ruin economies, disrupts social connections, and exacerbate political tensions (Jamison et al., 2017). Huremovi RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 12 (2019) cited that several global severe health disease outbreaks have threatened humankind in the twentieth century to the current era, such as the "Spanish Flu," Yugoslavia's Smallpox, HIV, severe acute respiratory syndrome (SARS), swine flu, Ebola, and Zika. Nevertheless, given that humanity has suffered and endured multiple outbreaks of infectious illnesses in its existence, the most recent global pandemic proved that human civilization continues to be ill-prepared and vulnerable to destruction from its indiscriminate onslaught. The Coronavirus Disease 2019 (COVID-19) Outbreak On December 1, 2019, experts reported the first symptoms of a disease that would impact the lives of all human beings in the world for months and eventually be known as the COVID-19 pandemic (Liu et al., 2020). Cases of illness characterized by pneumonia symptomatology with or without accompanying gastrointestinal disorder started to show up in almost 2/3 of the employees in a seafood market in Wuhan, one of the Hunan province cities in China (Shereen et al., 2020). Wu et al. (2020) reported that Wuhan's local health officials eventually gave the epidemiological warning on December 31, 2019, which prompted the seafood market's closing the following day. However, the ensuing months gave testament to the high rate of human-tohuman transmissibility and fatality of COVID-19 as it quickly spread in China, and in only fiftyfive days, it infected greater than 70,000 people with a reported mortality rate of more than 1,800 (Shereen et al., 2020). COVID-19 eventually spread rapidly worldwide and became a global pandemic in approximately two months (Wu et al., 2020). The World Health Organization (WHO) reported on October 11, 2020, that there were 36,754,395 infections and 1,064,838 mortalities confirmed in 235 countries, regions, and territories globally (WHO, 2020). RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 13 COVID-19 in the U.S. In the U.S., the nations public health agency reported the first COVID-19 infection on January 21, 2020 (Centers for Disease Control and Prevention [CDC], 2020). However, the government's initial reaction during the early part of the pandemic was to diminish the threat of COVID-19 (Weible et al., 2020). During the proceeding months, it became apparent that there was disorganization, poor strategic planning, and lack of political will among the federal, state, and local government officials and within public health agencies as the rate of infections and mortalities continued to rise (Haffajee & Mello, 2020). In just two months from the first reported case, the number of infections grew to 235,000 all over the U.S. (Omer et al., 2020). Ten months later, on October 12, 2020, the CDC confirmed 7,740,934 COVID-19 infections and 214,108 deaths in the U.S. (CDC, 2020). Parodi and Liu (2020) reported that the U.S. government and public health agency's initial strategic plan to combat the spread of COVID-19 was containment or quarantine. However, the containment strategy failed as infection rates increased in California and New York City due to lack of facilities (isolation rooms), medical personnel, personal protective equipment, and other disposable medical equipment such as surgical masks (Parodi & Liu, 2020). To augment the effect of containment, the CDC recommended implementing a community mitigation protocol, which all state governments enforced (Lasry et al., 2020). The proposed strategies included universal personal protective measures such as frequent handwashing and covering of mouth and nose (mask), social distancing, and disinfecting surfaces (Lasry et al., 2020). However, because of competing policies between the CDC and the White House, compliance with community mitigation guidelines in the U.S. has been highly politicized and RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 14 contentious (Wiley, 2020). Arguably, the absence of transparency and lack of accountability in government leadership contributed to the U.S. struggle to control the spread of COVID19. Quinn and Kumar (2014) suggested that groups of the population are more at risk of struggling to cope during pandemics in U.S. society. Specifically, these vulnerable people during COVID-19 in the U.S. include the homeless, Native American, African American, Hispanic/Latinos, immigrants, non-citizen, older adults, as well as individuals with financial difficulties, mental health conditions, substance abuse problems, physical impairments, and medical issues (Douglas et al., 2020; Mesa Vieira et al., 2020). Vulnerable Populations During COVID-19 Racial/Ethnic Minorities and Immigrants Due to long-standing systemic inequities and inequality, many racial and ethnic minorities and immigrants have low socioeconomic status, have inadequate healthcare insurance coverage, and hold jobs in retail, food service, custodial, transportation, and healthcare industries (Laurencin & McClinton, 2020). During the COVID-19 pandemic, the Cybersecurity and Infrastructure Security Agency (CISA) of the U.S. Department of Homeland Security issued a public directive which designated specific infrastructure workforces' operation and services in public and private sectors nationally, statewide, and locally to be critically essential to meet the needs of the citizens (CISA, 2020). The list of crucial workforce establishments provided by CISA (2020) included healthcare, food, agriculture, police force, first responders, energy, water, wastewater, public works, transportation, communication, information technology, critical manufacturing, hazardous materials, financial services, chemical, defense industrial base, residential/shelter facilities and services, and hygiene products and services. Dorn et al. (2020) posited that many workers in a number of these essential business establishments such as grocery RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 15 stores, factories, public transits, nursing homes, hospitals, first responders, agriculture, and government offices are immigrants and racial and ethnic minorities. Therefore, the racial and ethnic minorities (African Americans, Hispanics/Latinos, and Asians) and immigrants who were already suffering from economic and health inequities and inequalities were disproportionately affected compared to other population groups during the COVID-19 pandemic (Bambra, 2020). Specifically, being an essential worker during the COVID-19 pandemic means continuing to work, which increases the risk of exposure to the disease and spreading it to family members. McCormack et al. (2020) estimated that 40% of adults in the U.S. were essential workers, based on the updated 2018 American Community Survey (ACS). Out of these essential workers, 14% were African American, and 17% were Latin Americans. Using classifications that attempt to define households' economic susceptibility, McCormack et al. (2020) approximated 13% comprised of homes with low income (<$40,000), were uninsured, and had at least one resident at 65 years old or older. The results of another study that accounted for socioeconomic determinants of participants from seven densely populated states (New York, Michigan, Massachusetts, Pennsylvania, New Jersey, California, and Louisiana) suggested that African Americans are almost three times more likely to die from COVID-19 infection than nonHispanic whites (Abedi et al., 2020). Individuals Experiencing Homelessness, Substance Abuse Problems, and Physical Impairments Individuals who suffer from substance abuse and mental health disorders worsen of their symptoms because of loneliness, depression, and anxiety brought on by the shelter in place mandate (Galea et al., 2020). Homeless people with health problems and do not have access to cleaning facilities and hygienic paraphernalia and are forced to stay in crowded living RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 16 arrangements increase their chance of acquiring COVID-19 (Tsai & Wilson, 2020). In the case of individuals with physical difficulties, many are financially challenged, have chronic health problems, and live in group homes, which increases their susceptibility to contracting COVID-19 (Turk & McDermott, 2020). Older Adults According to the CDC, as of September 2020, individuals sixty-five years and older comprise eight out of ten deaths related to COVID-19 in the U.S. (CDC, 2020). A case series study of 5700 COVID-19 patients with the median age of 63 years old in New York City during the pandemic's height listed comorbidities of cancer, cardiovascular disease (hypertension, coronary artery disease, and congestive heart failure), chronic respiratory disease (asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea), HIV, organ transplant, liver diseases, obesity, and diabetes (Richardson et al., 2020). The social distancing part of the U.S. mitigation guidelines the CDC recommended, adopted by all the state governments, disparately impacted the lives, well-being, and health of vulnerable populations, especially older adults (Lasry et al., 2020; Mesa Vieira et al., 2020; Morrow-Howell et al., 2020). Consequently, for many CDOA, the COVID-19 social distancing protocol resulted in social isolation that exacerbated loneliness and depression and increased difficulty accessing healthcare services and delivery (Douglas et al., 2020; Wand et al., 2020). The protocol prevented community-dwelling older adults (CDOA) from getting to fitness centers, parks, community centers, churches, family members, and friends' houses, which dramatically reduced their physical activities, social interactions, and participation in their health care needs (Weible et al., 2020). Van Orden et al. (2020) posited that the lack of social connections in later years of people's lives could adversely impact older adults' health and well-being. The authors suggested RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 17 social isolation could promote and exacerbate medical and mental conditions such as cardiovascular disease (atherosclerosis, arteriosclerosis), type 2 diabetes, high blood pressure, perception of pain, suicidal tendency, cognitive deficits (dementia), sleep disorder, and physical exhaustion. Rural Community-Dwelling Older Adults Older adults are predicted to account for 20% of the U.S. population by 2030 (Chesser et al., 2016). Skoufalos et al. (2017) reported that 25% of older adults in the U.S. live in rural communities. In general, older adults' health care needs can be complicated and may require access to a wide range of successful management (Thorpe et al., 2011). In addition to having multiple health issues, most older adults exhibit age-related physical, mental, and cognitive changes that lead to functional difficulties (Chang et al., 2019; Tkatch et al., 2017; Yamada et al., 2015). Skoufalos et al. (2017) intimated that in rural communities, the lives of CDOA are negatively impacted by social and environmental determinants such as the exodus of the younger citizens, difficulty developing community partnerships, waning businesses, poorly funded local government, insufficient health care workers, and limited public and private infrastructure. Due to these challenges, rural CDOA generally presents with more ongoing multiple health problems, infirmity and are less likely to engage in a healthy lifestyle (Skoufalos et al., 2017). Therefore, rural CDOAs are more vulnerable to the adverse effects of COVID-19 and have more difficulty meeting their health care needs during the pandemic than their urban counterparts. Challenges for Rural CDOA During COVID-19 Pandemic Many older adults in North America live alone, and those with declining health face many challenges in meeting life's necessities and healthcare needs (Morrow-Howell et al., 2020; Naja & Hamadeh, 2020; Reher & Requena, 2018)). Due to age-related physical deficits and medical RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 18 issues, some rural CDOA already have difficulty leaving their home and are dependent on transportation or visitations from friends and family members for appointments (including medical), shopping, and socialization. The "shelter in place" mandate during the COVID-19 pandemic disrupted the already inadequate healthcare system, public and private social support system and exacerbated the disparities in health care delivery and services for the CDOA in rural communities (Henning-Smith, 2020; Morrow-Howell et al., 2020; Naja & Hamadeh, 2020). Social distancing made the lives of CDOA in rural communities even more isolated by limiting attendance and group activities that provide psychosocial support (Morrow-Howell et al., 2020). Rural CDOA who have multiple chronic medical conditions are highly sensitive to sudden interruptions of public and private functional support caused by the stay-at-home ordinance (Steinman et al., 2020). Social disconnectedness can promote anxiety and depression, resulting in reduced motivation for physical activity, which is more debilitating for CDOA (Morrow-Howell et al., 2020; Santini et al., 2020). The inability to get to grocery stores or fresh food markets forced some CDOA to rely on food laden with preservatives that exacerbate chronic illnesses such as hypertension, congestive heart failure, and diabetes (Steinman et al., 2020). One of the consequences that stemmed from the CDC mitigation protocol is the healthcare providers' advocacy to use digital technologies to conduct remote meetings (Wosik et al., 2020). However, for some older adults, the use of technology can be very intimidating and thus becomes a barrier in health management (Fischer et al., 2014; Vaportzis et al., 2017). This suggestion is supported by Tsai et al.s (2017) study, which reported that older adults have the lowest adjustment rate and are slow to adapt to the required skills and efficacy needed with digital technologies. Age-related physical, mental, and cognitive changes, low socioeconomic RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 19 status, and reluctant stance against technology are additional factors associated with low utilization of digital technologies in health care management among older adults (Y.-H. Wu et al., 2015). Positive Role of Technology for Rural CDOA The digital age yields advancements in medical technologies that promise to improve health care delivery and the quality of life for patients with chronic illnesses (Mesk et al., 2017). Gordon and Hornbrook (2018) suggested that older adults are the most affected demographic by the steady transition from analog to digital health care access and delivery. Modern technological innovations have encouraged older adults to control their health and wellbeing (Manafo & Wong, 2012), and they have shown increased interest in the use of digital devices such as smartphones and tablets (Morrow-Howell et al., 2020; Vaportzis et al., 2017). The three main uses of digital technology that can have a positive impact on the lives of rural CDOA are socialization, increased access to health care through telemedicine, and providing therapeutic interventions via digital therapeutics (Chopik, 2016; Kaufman & Khurana, 20161/27/2022 1:58:00 PM; van Houwelingen et al., 2018). Social interactions through the use of the internet among older adults have reduced loneliness and depression, promoting a more positive outlook and life satisfaction (Chopik, 2016). Among older rural veterans, the use of telemedicine through synchronous (real-time virtual meetings), recorded (registering then forwarding data), and remote monitoring (health care providers watching health information) not only increased access to health care delivery and services but also improved quality of life for both the veterans and caregivers (Lum et al., 2020). A randomized control trial study of homebound CDOA with chronic pulmonary obstructive disease and heart failure receiving home RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 20 health care services supplemented by telehealth showed decreased emergency department visits and depression feelings among the treatment group (Gellis et al., 2012). Digital therapeutics (DT) is a treatment procedure wherein an intervention is delivered automatically through wearable digital devices (Berman et al., 2018). An example is the use of digital therapeutics as an aid in glucose monitoring, which has been shown to improve compliance and promote self-efficacy in managing type 2 diabetes (T2DM) in older adults (Kaufman & Khurana, 2016). Cafazzo (2019), however, intimated that since DT is in a relative infancy stage, the adoption of its use has not quite reached a critical point of mainstream application. Also, there are no evidence-based studies that support the validity and reliability of the use of DT (Cafazzo, 2019). However, based on currently available research, DT can play a positive role in the health care management of rural CDOA with T2DM during pandemics. Gap in the Literature There has not been a global health crisis comparable to the magnitude of COVID-19 since the 1968 H3N2 influenza pandemic (Jackson et al., 2010). The COVID-19 and H2N2 pathogens threatened older adults' health directly and indirectly (Douglas et al., 2020; Jackson et al., 2010; Mesa Vieira et al., 2020). CDOA, in general, has been one of the vulnerable populations suffering the most during the recent global pandemic (Douglas et al., 2020; Mesa Vieira et al., 2020). As cited earlier, studies have investigated the indirect adverse effects of COVID-19 mitigation protocol related to how the health care needs of the general CDOA are met (Emanuel et al., 2020; Morrow-Howell et al., 2020; Steinman et al., 2020). However, to date, no studies attempt to understand the experiences of rural CDOA in meeting their healthcare needs during the COVID-19 pandemic. Results from this study that seeks to understand the healthcare and social isolation experience of CDOA with multiple chronic diseases during the RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 21 COVID-19 pandemic will be useful for public health experts and government officials in developing effective response plans to mitigate the effects of the next global health crisis. Method Study Design The researcher utilized a qualitative, phenomenological approach in understanding the meaning of the lived experiences of CDOA with multiple chronic conditions during the COVID19 pandemic. Davidsen (2013) advanced that, as used in qualitative research, phenomenology is based on a philosophical concept that attempts to understand human experiences as a unique phenomenon for each individual. Accordingly, phenomenological qualitative research is concerned with unraveling the complexities of human lived experiences (phenomenon) into relatable descriptions that approximate the phenomenon's essence (Davidsen, 2013). An interpretive rather than a descriptive type of phenomenological methodology for analyzing the target phenomenon was employed in this study. Specifically, the hermeneutic phenomenological approach used is a systematic collaborative process between the investigators and participants, in which meaningful interpretations are created through repeated readings, introspections, and explications (Laverty, 2003). The articulated personal lived experiences of the rural CDOA were transcribed into texts, then explored and repeatedly analyzed for meaningful themes that best describe the essence of the participants' lived experiences related to health care during the COVID-19 pandemic (Sloan & Bowe, 2014). The researcher solicited participants' thoughts, opinions, clarifications, concerns, and approval of the transcripts and final interpretation of their lived experiences. Before conducting any research activities, the primary investigator obtained approval for the study from the University of Indianapolis (UIndy) Institutional Review Board ([Appendix A] IRB). RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 22 Participants A purposeful sampling of individuals was used for this study. Creswell and Poth (2018) suggested that purposeful sampling ensures the chosen participants are the best representatives since they have first-hand knowledge of their individual and shared lived experiences of the problem, issue, event, experience, or phenomenon observed in a study. In selecting participants, this study utilized the criterion sampling strategy. Patton (2002, as cited in Palinkas et al., 2015) described purposeful sampling strategies based on specific objectives of selecting a group or population representative of the phenomena studied. Criterion sampling is one strategy in which the method of selecting participants depends on specified characteristics or criteria. Individuals selected from criterion sampling strategies are presumed to be well-informed, have experienced the studied phenomenon, clearly articulate their encounter, and are willing participants (Palinkas et al., 2015). For these reasons, criterion sampling was used in this phenomenological study. Individuals invited to this study met five inclusion criteria: geographic location (rural community as defined on page four) age (65 years old and older) medical conditions (two or more chronic diseases) English language proficiency cognitive and psychological competency (no diagnosis of Alzheimer's disease, any types of dementia, dissociative, schizophrenia, personality disorder; successfully demonstrate teach-back method for comprehension) The sample for this study included ten participants. Moser and Korstjens (2018) intimated that the power of small sample sizes is amplified by the profusion of information from the participants' interviews. Since this was a phenomenological research study that used semi- RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 23 structured interviews, it was expected to produce robust data from each participant (Creswell & Poth, 2018). Morse (2015) suggested that the directness and familiarity of the phenomenon to the participants offers a casual and relaxed atmosphere fostering an open interaction. Therefore, the combination of purposeful sampling and the use of well-planned semi-structured interviews should produce a meaningful interpretation of the lived experiences of rural CDOA meeting their health care needs during the COVID-19 pandemic. Setting The setting for this research study was the rural communities of the states of Indiana and Ohio. These are areas served by Reid Home Health Care (RHHC), a home health agency located in Richmond, Indiana, where the primary investigator (PI) is employed as a full-time physical therapist. It provides skilled professional healthcare services to community-dwelling older adults for seven counties in Indiana and two counties in Ohio with an approximately combined coverage area of a 50-mile radius. Since this study involved reviews of patients' medical records, permission had to be granted by RHHC through the letter of cooperation (Appendix B). It included signed statements acknowledging familiarity of the research's function, a detailed plan for collaboration, outlined responsibilities, and consent by a recognized official representative of RHHC. Part of the letter also specified opportunities to ask questions that were provided to the RHHC official signatory. Procedures Recruitment Recruitment of participants involved seven processes: secure contact and recruitment permission approval flyer dissemination RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE prospective participants responses teach-back method for comprehension competency screening medical record review for inclusion criteria 24 selected participants notification scheduling of consent signing and semi-structured interview Since this study involved reviews of patients' medical records, permission had to be granted by RHHC corporate authority. The burden of responsibility, ensuring patients' rights and privacy are respected and protected, falls onto the researchers. As an employee of RHHC, it was incumbent upon the PI to follow ethical prudence by pre-disclosing any activities outside of employment boundaries. Therefore, full disclosure of the study and acquisition of permission from the corresponding authorities at RHHC was the first step in the recruitment process. A letter of cooperation was drafted and sent to the corporate head of clinical services of the parent company of RHHC (Appendix B). It included a concise description of the research project, processes established to uphold bioethical principles (autonomy, justice, beneficence, nonmaleficence), participants' identity protection, affiliated institution, and the HRPPIRB involved. Part of the letter also specified opportunities for the authorized person to ask questions. The PI secured signed statements acknowledging familiarity of the research's function, a detailed plan for collaboration, outlined responsibilities, and consent by the corporate privacy officer of RHHC before contacting and recruiting prospective participants (Appendix C). This study used flyers to disseminate information and request participation (Appendix D). Information on the flyers consisted detailed summary of the study purpose, confidential methods, duration of commitment, and the PIs contact information, all written at 5th-grade level readability. The U.S. Government Accountability Office (2006, as cited in Stossel et al., 2012) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 25 suggested that Medicare beneficiaries, on average, read at the 5th-grade level. As such, the Flesch Reading Ease (FRE) readability formula was employed to ensure the flyers' written contents were at the 5th-grade level to be clear, simple, and easy to understand. It is a commonly used assessment formula that ranks the reading difficulty of written documents using a 100-point scale with higher scores correspond to easier readability, and fifth-grade level readability is at 90-100 points (Zamanian & Heydari, 2012). The FRE readability formula is integrated into the Microsoft Office 365 Word processor the researchers used to create the participants' required written documents, such as flyers, consent forms, interview guides, and transcripts. The flyer clearly stated that eligibility would be confirmed via a review of the potential participants medical record. The solicitation of permission to review patients' medical records complies with the Health Insurance Portability and Accountability Act mandate to protect the patients' privacy, confidentiality, and autonomy (U.S. Department of Health and Human Services, 2013). Also included in the flyers was an explicit statement emphasizing that participation in the study was not connected to their care and would not affect the health services provided to them by RHHC, whether they chose to participate or not. Since the participants in this study were actual patients, the health care services received from RHHC would be expected to influence the accounts of the participants' experiences. Therefore, participants selected were patients who received services from RHHC within a specific time frame. For this study, December 2020 to July 2021 was the period selected for recruitments to ensure uniformity of participants' shared lived experiences with RHHC during the COVID-19 pandemic. The PI asked clinical coworkers (registered nurses, licensed practical nurses, physical therapists, physical therapist assistants, occupational therapists, certified occupational therapist assistants, speech-language pathologist) to help deliver flyers and give a brief general RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 26 explanation of the intent of the flyers to new and current patients (potential participants) during scheduled appointments. Before requesting their help, the PI gave coworkers a detailed explanation of the study's intent and the flyer's purpose in recruitment. Along with the standard patient orientation literature, flyers for this study were included in the start-of-care (SOC) folder provided by RHHC to new patients on every admission visit. In the home health care setting, a registered nurse, the physical therapist, or the speech therapist are the health care professionals who can conduct patient admission visits (SOC). The SOC folder includes pieces of information necessary for patients' orientation to home health care services. It includes RHHC contact information, explanations of Medicare guidelines, patient's bill of rights and responsibilities, COVID-19 education, a calendar for scheduling visits, and disease-specific management pathways. The admitting healthcare professional explain all information included in the SOC folder. For patients RHHC already admitted, flyers were handed and explained by all of the PI's clinical coworkers to the patients. Each prospective patient was requested to notify the PI by phone within one week of receiving the flyer if they were interested in the study. A one-week time frame was chosen to allow enough time for the potential participants to ponder alone or with assistance from caregivers and make the appropriate personal decision about whether to participate or not in this study. The flyer's contents also included an instruction to call the PI for clarifications and questions at any time. The PI also contacted potential participants who had not checked in after a week and determined their decision. To ensure that participants could give informed consent, the PI used the teach-back method to screen for the study's comprehension. The teach-back approach allows participants to be prompted to explain or summarize the provided information (Yen & Leasure, 2019). Chin et al. (2015) suggested conscious reasoning and understanding are RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 27 dependent on well-functioning mental processes that involve memory recall and analytical thinking (Chin et al., 2015; Yen & Leasure, 2019). Therefore, participants who summarized the study's purpose successfully based on the flyers' information were determined to demonstrate a sufficient understanding of the study and deemed competent to provide consent. This process also confirmed participants fluency in the English language. The PI reviewed participants' medical records who passed the teach-back screening against the established selection criteria as the final step for inclusion in the study. The medical records compiled, secured, and protected by RHHC include comprehensive demographics, physician-confirmed medical diagnoses, and the spoken languages of each of the patients. After criterion selection screening completion, the PI notified potential participants whether they were selected or not for the study, that the consent procedure, then the semi-structured interview, was next in the research process over the phone. The PI explained to the participants that an information sheet containing a simple summary of the purpose of the study, the methods involved, date and place, length of participation, and consequences, would be used for informed consent for this study in the same phone call. Agreement to the semi-structured interview meant consenting to participate in the research study. The semi-structured interview was held two weeks after the selection completion and notification. Informed Consent A study information sheet was personally delivered to selected participants under the PI's direct care during scheduled appointment visits and mailed to those who were not, at least one week before the interview (Appendix E). The one-week period provided ample time for the participants to review the information sheet's language and meaning ahead of the interview. The participants were also instructed to call the PI for any questions and clarifications before the RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 28 scheduled interview. The COVID-19 mitigation protocols, such as wearing masks and gloves, were followed when preparing and delivering the information sheet documents. This study employed Kadam's (2017) process of acquiring unbiased and objective informed consent, which involves full disclosure of information, competence, understanding (comprehension), and self-determination (voluntariness). Kadam (2017) suggested that researchers write detailed explanations and descriptions of the study's purpose and methods in simple and understandable language devoid of sophisticated and technical vocabulary. This method ensures comprehension, including the risks and benefits of participating in the study (Kadam, 2017). Verbal informed consent instead of signatures was used in this study to confirm authorized voluntary agreement to participate to avoid gathering identifiable information. Obtaining verbal consent was conducted under the UIndy IRB committee's approved process. An information sheet was used as the consent document, which included steps to protect privacy and participants' right to decline to answer any interview questions and withdraw from the study at any time. The information sheet document included statements that reflected respect for cultural norms, religious convictions, political ideology, and social issue sentiments (Creswell & Creswell, 2018). Also included was an explicit statement emphasizing that participation in the study was not connected to their care and, therefore, would not affect the health services provided to them by RHHC. The information sheet also stated that participants understand the study's purpose, risks, and benefits to willingly consent to participate verbally. The interview was conducted after verbal consent was obtained. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 29 Data Collection Process This study's primary data collection method was an individual semi-structured interview with each participant, directed by an interview guide (Appendix F). DeJonckheere and Vaughn (2019) posited that a semi-structured interview offers a relaxed atmosphere for discussion and consists of open-ended questions that motivate participants to share the essence of their lived experience of the studied phenomenon. The PI offered to interview in a place providing safety, security, and privacy for both interviewee and interviewer. Since the pandemic was still active during consent acquisition and interview, the participants were given options to meet face-to-face in their homes or remotely via video conferencing. All participants opted for a face-to-face meeting. Therefore, both the PI and the participants strictly followed the CDC COVID-19 mitigation protocol. The temperature of both the PI and participant were taken, mask-wearing, hand washing, hand sanitation, and at least six feet distancing were enforced before the start of the process. All devices used during the interview, such as a thermometer, stylus pen, and digital tablets, were sanitized following CDC guidelines. Participants were allowed to state answers to each question for as long as needed until the interviewee had no more experiences to share. The interview length varied, with 25 minutes as the shortest and 61 minutes as the longest. At least three digital audio recorders (DAR) recorded the dialog between the participants and primary researcher during the interviews. The interview questions were designed to encourage rich and deep responses, involving in-depth information concerning this study's primary focus. The interviewer began the interview with broad questions about the participants' lives before and after COVID, followed by more focused questions about critical aspects of their lives such as social, shopping, recreational, RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 30 physical fitness, and health care habits and activities during those periods. The follow-up questions focused on the perceptions about changes the COVID-19 pandemic caused in the participants' way of living and the impact of social isolation. The final question explored participants' recommendations and suggestions about how health care providers and public health officials could be better prepared to help rural CDOA meet their health care needs during the next pandemic. Before ending each interview, the PI informed the participants that a two-part memberchecking process would be scheduled, with the first check taking place two weeks after the interview. The interviewer explained that the first part of member-checking is a process by which the recorded interview would be transcribed (recorded voice made into a written record) and sent to the participants for feedback to account for the accuracy of transcription of the shared lived experiences (Creswell & Poth, 2018). Member-checking gives the participants a sense of authority, ownership, and control over their responses (Merro-Jaffe, 2011). The printed copies of the transcribed interview were sent to the participants by regular mail or email with instructions for them to read their answers and make appropriate changes carefully. Included with the printed transcripts were instructions to the participants to underline or circle words or phrases that need corrections, then write appropriate changes and comments above or below the terms to be adjusted or in the transcription's right-hand margin (Appendix G). Another option was to number the circled and underlined words and phrases for corrections, then write the corresponding changes and comments on a separate paper. Once changes were completed, participants were advised to mail back the printed transcriptions with the amendments using the prepaid envelope provided. If verbal corrections were preferred, options to make changes face-to-face or by phone were provided. Participants who opted to receive the RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 31 transcripts by email were instructed to make the changes using Microsoft Word's "track changes" tool, then email back the transcripts with revisions to the research investigator. If needed, the PI planned to provide lessons or instructions on using the Microsoft Word "track and change" tool to make comments, suggestions, and revisions. Only one of the participants chose to accept the transcripts through email, and the rest asked to have the transcripts sent via postal mail. Data Management and Analysis Audio recordings of the interviews were uploaded to a password-protected computer and removed from the digital audio recorder immediately after each interview. The uploaded data was transcribed using Temi, an app that provides audio to text transcription. Temi uses the highest encryption level protection for storing and transmitting data. The transcribed data was cleaned and de-identified, then downloaded and exported as Microsoft Word documents. The PI sent the transcripts of interviews to each of the corresponding participants for the first memberchecking. Participants' corrections, revisions, and additions were then added to the transcribed data. Dedoose (version 8.3.35), a qualitative data analysis software program that allows collaborative work and offers high-security protection, was used for data analysis. The data analysis process for this study was patterned on Colaizzi's phenomenological data analysis approach (Figure 1) that includes seven phases (Morrow et al., 2015). To make meaningful interpretations of the data and strengthen this study's credibility, two researchers (coders) engaged in the data analysis process (Creswell & Poth, 2018; Henderson & Rheault, 2004). The researchers met initially to come to a mutual understanding of the study's aims, objectives, and purpose before initiating data analysis. Having a shared perspective provides coders a good contextual foundation for interpreting data and producing complementary themes. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 32 Repeated readings of each participant's initial transcripts to develop a deeper understanding and familiarity with the lived experiences served as the data analysis first phase. The second phase involved drawing out specific phrases and sentences from the participants' transcribed interviews with distinctive characteristics and substantive meanings related to the study's research questions and aims. The researchers initially completed this process individually for each of the participants' transcripts, then later compared findings for agreement of statements, expressions, clauses, and sentences that closely described lived experiences related to meeting the rural CDOA health care needs. The qualitative analysis process, specifically the code cooccurrence and code application function of Dedoose, was used to compare the researchers' findings. Since raw data was the primary source of information in this study, the deconstruction (winnowing) of information into concise but meaningful phrases was guided by inductive analysis or open coding (DeCuir-Gunby et al., 2010). In the third phase, the extracted phrases, and sentences from phase two were assigned descriptions for distinctive categories and characteristics, which served as the initial themes. At this stage, since these are preliminary themes, the descriptions used had broad meanings. Also, in this third phase, the researchers created a codebook (Table 2), which was used to promote dependability since it was based upon the agreement between multiple researchers (DeCuirGunby et al., 2011). It also served as a reference guide for the researchers throughout data analysis and provided transparent justification for the selected codes. In stage four, the researchers repeated the processes from phase one to three for each transcribed participant's interview. This stage narrowed down the broad themes produced from phase one to three into all-embracing (final themes) representations of the participants' shared lived experiences (Table 3). The themes were examined for associations and relationships of RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 33 their descriptions. The initial themes with close association were grouped to form final themes with corresponding sub-themes, and themes found to have no relationships with other themes were established as part of the final themes. Comprehensive descriptions of the final themes characterized the fifth phase. The researchers made in-depth interpretations of the final themes that provided a deeper understanding of the participants' perceptions of how the COVID-19 pandemic affected the ability to meet their health care needs. The refinement of the exhaustive interpretations of the final themes characterized the sixth phase. Through coordinated repeated reviews, the researchers corrected any redundant, misinterpreted (under- or over-interpreted), unnecessary, and superfluous descriptions. This process allowed in-depth but concise descriptions of the final themes. Revisions were also added to emphasize how the interrelationships of the final themes represented a deeper meaning of the shared lived experiences of the participants related to meeting their health care needs during the pandemic. Finally, the seventh phase involved the second part of member-checking. The final themes were the researchers' interpretation of the essence of the participants' lived experiences related to the study's purpose through comprehensive data analysis using Colaizzi's method. The second member-checking was completed to gain participants' feedback and validate the researchers' interpretations of their shared lived experiences. A narrative summary of the final themes was created for the participants, and it was written in simple words, phrases, and statements for easy readability (Appendix H). Similar to the process used for the first memberchecking, the narrative summary was sent to participants via postal mail and email with a letter of instructions for responding (Appendix I). It took a total of sixteen weeks to develop the narrative descriptions of the participants' interviews. The research coders spent thirteen weeks on RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 34 data analysis to produce the preliminary narrative descriptions. All the research project members spent another three weeks collaborating to ensure that the developed narrative descriptions were the closest possible interpretations of the participants' shared lived experiences related to meeting their health care needs during the COVID-19 pandemic. All participants' responses were received in two weeks. Rigor and Trustworthiness Qualitative researchs reliability and validity depend on the studys trustworthiness or rigor (Morse et al., 2002). Absent the integrity or precision, research studies purpose becomes useless assumptions (Morse et al., 2002). This study adopted Gubas Model of Trustworthiness, which has four criteria: credibility, transferability, dependability, and confirmability (Henderson & Rheault, 2004). Member checking, wherein the participants review, substantiate, and, or modify the interpretations of the accounts of their lived experiences, was used to attest the credibility of this research study project (Cresswell & Poth, 2018). Each participant scrutinized their own experiences on the initial transcripts of the interview and its final interpretations, ensuring that member checking was personalized (Morse et al., 2002). Transferability was addressed by deliberately designing the studys context, sampling strategy, sample population, demographics, study design, inclusion, and exclusion criteria to represent the general rural CDOA with multiple chronic diseases population during the COVID-19 pandemic (Korstjen & Moser, 2017). An audit trail, or methodical description, of the research method processes from preplanning, choice of health issue and setting, participant selection, interview, transcription of data, coding, and interpretation of results appraised this studys dependability (Henderson & Rheault, 2004). Expert scrutiny of the audit trail was employed to strengthen this research studys RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 35 dependability (Henderson & Rheault, 2004). The research committee members of this project provided the expert examination of the audit trail. The triangulation method was used for confirmability in this research project (Henderson & Rheault, 2004). At least two research investigators (coders) with expertise on the phenomenon being studied analyzed the same data (Fusch et al., 2018). The PI and an external researcher are both experienced healthcare providers for the population and phenomenon studied, served as the investigator triangulation sources in this study. The PI and the external researcher, acting as coders, collaborated in data analysis and corroborated interpretations repeatedly throughout the seven-step process of Colaizzi's method, ensuring the accuracy of results. Some of the participants in this study were patients of the PI (interviewer). Understanding individuals medical, physical, and mental conditions, especially older adults, to provide or facilitate appropriate health care services defines the interviewers professional work. Familiarity with participants chosen for the interview and problems related to their health care issues facilitated natural and cordial interactions during the interview. However, these situations created a potential bias on the interviewers part. Since the PI was acquainted with some of the participants health issues and is an experienced health care provider, the risk of unintentional acts of posing leading questions was high. To enhance credibility, the researcher also used bracketing in addition to Gubas Model of Trustworthiness. The PI addressed concerns regarding bias by bracketing in three ways. First, the PI clearly and fully disclosed his profession, familiarity with some participants, and affiliation with the home health agency (RHHC) involved. Revealing the investigators background related to the phenomenon, it allows the public to discern whether participants shared their lived experiences were uninfluenced by the researcher (Creswell & Poth, 2018). Second, the interview RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 36 guide used, which experts vetted, included questions that deliberately evoked participants lived experiences and elicited personal responses related to the phenomenon. Third, Colaizzis phenomenological data analysis method provided a process that allowed the data to draw more profound and meaningful interpretations of the participants experiences without researchers (coders) personal perspectives interjections (Figure 1). Results Ten rural CDOA who met the criterion sampling requirements participated in the interview for this study (Table 1). All participants chose their own homes for the interviews, which lasted 25 61 minutes in length. Participants included eight females and two males with at least three chronic medical diagnoses and ranged from 65 82 years old. Eight of the participants live in Indiana, two in Ohio, and all received home health care services from RHHC. Based on their shared lived experiences through interviews, the participants in this study were presented with new challenges due to the COVID-19 pandemic related to meeting their health care needs. However, they showed resiliency, resourcefulness, perseverance, adaptation, and reliance on faith to overcome the barriers imposed by the COVID-19 pandemic. Following rigorous analysis of the data using Colaizzi's phenomenological method, the main themes reflecting participants' perceptions of factors affecting the ability to meet their health care needs were Lifestyle Changes, Health and Wellbeing, Access to Health Care Services, and Use of Technology (Figure 2). Each theme has sub-themes. Ironically, the ordered safety measures during the COVID-19 pandemic, including the stay-at-home mandate, social distancing, and mask-wearing that were supposed to protect the health of everyone, including the rural CDOA, were perceived by participants as barriers to meeting their health care needs. Participants' experiences suggested that the mitigation mandate RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 37 and protocols were the predominant causes of the adverse changes in their Lifestyle, Health and Wellbeing, and Access to Health Care Services. These adverse changes to certain aspects of their lives encouraged the use of technology for healthcare services access, social connections, hobbies, and entertainment. In the subsequent discussions of themes, some of the participants' accounts implied that the mitigation mandate and protocols caused a significant decrease in physical activities (lifestyle changes), which exacerbated participants' chronic conditions (health and wellbeing), necessitating access to health care services (appointments, treatment, interventions, pharmacology) using technology (Figure 3). Also common to most of the participants' reflections is that the mitigation mandate and protocols prompted isolation (lifestyle changes - limiting socialization) that led to depression (health and wellbeing - mental and emotional stress) and forced participants to use coping mechanisms such as increased use of technology (social media, genealogy, streaming videos, virtual conversations). At the end of the interview, participants were asked for advice on how health care experts and government authorities could best help rural CDOA in the next pandemic. The probing question elicited a variety of recommendations that encompassed multiple sectors of society related to health care. Participants also recognized their responsibilities to be well informed and cooperative with safety mandates in a healthcare crisis. Theme 1: Lifestyle Changes Physical Activity Most of the participants felt physical activities became restricted and limited, affecting the drive to stay active. My motivation to be physically active has really been affected that I dont want to do nothing. I just want to lay around all the time and sleep, and I have to make RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 38 myself get up and do stuff (231008). Walking with friends at the park abruptly halted. Oh, my friend and I used to go up to Devin Park, and we used to walk around to the ball diamond, but that stopped (020218). Routine daily activity such as walking the dog was put on hold. Oh, Im terrible. I walked my dog all over the neighborhood, and now I cant even walk my dog. And that is frustrating because Im tied in the house. Its like, somebodys got a rope tied around me and say, youre physically not able. And youre useless. (231008) However, for another, dog walking continued but carefully kept at a distance from others. I would still take walks around the neighborhood, and I did not wear a mask. I felt like the fresh air was important for me. Exercising absolutely was necessary for my back problem at the time. I usually walked alone with my dog, but I was seeing neighbors up and down the street. And if they would come out and talk, we would visit, we would keep our distance. I dont recall wearing a mask at that time because I felt like I was in the fresh air, and we were far enough apart. Had they come closer? Yes, I would have put my mask on. (100319) Socialization The participants' experiences suggested that the COVID-19 pandemic affected their health and wellbeing and touched every aspect of their lives. There are certain parts of life participants mentioned that affected them more deeply than others. Participants knew that the mitigation protocol affected local business establishments' commerce, and their shared lived experiences reflected this sentiment. They felt a strong sense of responsibility and belongingness to their communities and made efforts to help their local community business establishments buy buying most of their necessities locally. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 39 if there is something I can buy in town, I try to buy it in town because I want to keep as many businesses here as possible. (130108) ... we have used the community more. Uh, weve been ordering meals in, from local restaurants in town that are healthy. Um, we have like the Krogers program. (100619) One participant described an instance of taking the time to write and send out occasional (birthdays) and general greeting cards to members of her church community to show support and encouragement. I try to, with my church group, I try to every week write at least three cards and send them to people just saying, thinking of you, or, you know, its your birthday happy birthday or whatever, because I feel like were not being able to gather in church were so out of touch and the church family is, you know, it was an important part of my life. (130108) Attending churches for worshipping and fellowship could not be practiced. Bible study, singing in church, Wednesday night, neighbor nights dinners at churchwe would go to church on Sundays...we were active... we had a Bible study that we were active with, and I was a worship leader at a church sang with the church...and that had to all stop. (100619) Some participants perceived that not practicing faith in their church is akin to losing the freedom to control certain aspects of their lives. by not being able to have something I want to get out and go to, it has been hard to set goals, to, you know, to try to strive, to get to a place where I can do this or get to a place where I can do that because they're outside of the house... well, more like going to church. (130108) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 40 The surge of COVID-19 infection from new variants and compliance with mitigation protocol club activities were suspended, which affected some participants' active social lives. I had a very active social life through my church, through my sorority through Helen Hunt club, uh, played Euchre once a week with a Euchre group... (130108). Some participants described that missing regular family get-togethers affected them terribly in a mentally and emotionally stressful way. I have a very large family and we got together once a month, all of us at our, my house. And theyd hardly be room to walk through the people and it abruptly stopped with this (COVID-19 pandemic) its one of the most horrible experiences in my 81 years, because Im eighty-one I live alone, and nobody can come and visit meIt changed family life. Its like, I can say for this whole time, I havent got to see part of my family and Ive got a granddaughter, like shes got five children and her sister has one and they got new babies during that time that I didnt get meet I just didnt feel comfortable to be around the kids because I didnt want to make them sick, but they were all staying away from me for fear making me sick. And it was miserable. (050820) For other participants, family gatherings, especially during holidays, added significantly to feelings of emptiness. "... Thanksgiving and such... could not do it because that would have been too many people... we're afraid to go, um, because we didn't have shots then... the holiday was missing...it was a big hole... And, um, that affected me (100619). However, some participants continued to meet with their loved ones but followed CDCs mitigation protocol. I continue to see my family that lives close, and we would observe the COVID-19 suggestions, you know, as far as wearing the mask washing, et cetera, et cetera, not hugging, not touching, but, uh, it didnt stop us really from getting together. We, we kept RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 41 our distance. We didnt hug, we did the fist-bump and the elbow-bump, but, uh, I cant say that I stopped seeing them. I did not, but we were very cautious. (100319) The sadness of not being with friends enjoying things they love to do, such as eating out, was expressed. I would go to dances or stuff or listen to music, meet with friends for go out and have dinner or something and all that come to an abrupt stop. (050820) I felt like I was a prisoner. Uh, couldnt see any of our friends and it effect it from the beginning to the very end and from the top to the bottom. (100713) ... it made me appreciate being able to be with family and friends. It made my life very lonely and still is to some extent, you know. (160919) Some participants' reflections insinuated that the inability to do mundane things that seemed simple and generally taken for granted, including face-to-face social interactions with friends, adversely affected their disposition. you know, you can talk on the telephone, but talking on the telephone is not hugging. Somebody talking on the telephone is not crying with somebody and talking on the telephone, although you can pray, it doesn't have the same intensity as when two or more people get together and pray together. (130108) One participant allowed visitations but was mindful of the mitigation protocols. at home, I, get, uh, visits from friends and, and family, and, uh, um, where, I can wear a mask here and at least see my family, or be with friends (130419). Shopping Habits Shopping habits were disrupted, and participants depended on other people to get their shopping necessities due to fear of being out in public. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 42 Before I, I did it on my own. I went to the grocery store, like any other person went shopping, but when COVID come around, I stopped. I didnt go anywhere. I stayed at home. My family did my grocery shopping. (020218) Nothing is open and, uh, I have to take my walker, or I have to have my wheelchair. And when you get out a bunch of people that dont wear their mask, so I quit going. (231008) Nevertheless, some participants continued to do their shopping but rigidly followed the mitigation protocols. Once they issued the warnings, I chose to be cautious to be careful. So, once they said to wear the mask, Ive worn the mask (100319). One participant regretted the decision to go out grocery shopping during the pandemic. Everybody picks it up and it looks at and turns it over. And then they reached behind the mask, rubbing their nose. So, Im trying not to do that when I see them doing it. But you dont know who done it before you got there and um, yeah, it kind of grossed me out and I went to Kroger one day and I got sneezing. I sneezed, I dont know how many times, all the way down, one on up the other. I finally, I just went through checkout. I got out of there before they kicked me out. (050820) Others started shopping by phone, online, and by using an app. ... we have been shopping by phone, um, and TV and then just typing. Yeah, computer... weve gone to Krogers Instacart (App), and they do our shopping and bring it to us (100619). The experience of delayed online ordered items frustrated one participant. ... a lot of reliance on online shopping, but I did that before. The only thing thats changed at the latter part of the pandemic was the whole mail situation in regard to online shopping. Because last year, at this time, you were still able to get things quickly, RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 43 especially youve got them from overseas. Now. Uh, what previously took two months is out to six months. (180503) One participant shared a disappointing experience from being forced to shop online for the first time because of the pandemic. I shopped in the stores mainly I didnt do much online at all because Im not very good on the computer, uh, um, my son calls me digitally challenged. Since COVID-19 I have a friend that would go and get groceries for me. Also, at the department store. I started buying online, which got me into trouble because Im not, good at using the computer. I got caught up in Wish. I dont know if you know what Wish is, yeah. And getting caught up in that was not good. Um, it sounded like a good thing, but then when I started getting the merchandise from there, a lot of the things were too small and you know, not what they showed. So, its been more confusing for me that way. (160919) Entertainment/Recreation In general, entertainment and recreation enjoyed out of their home alone or with family and friends were unable to be practiced during the pandemic. ... most of my recreational at that time was going out to eat prior to the COVID, uh, after doctors appointments. And so on, I would go to Menards or, spend the day out, uh to go to, uh, restaurants or, something of choice. But since Im home, recreational and entertainment has been the radio... dialing up on my cell phone, uh, comedians (streaming video) and so on, so forth. (130419) the churches were closed. The restaurants were closed. Theaters were closed, movies, uh, pretty much everything and people couldnt come in to visit. So pretty much isolated. (100713) I used to go to the Druids club, and RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 44 they dance had music there, but, uh, that just none of that could happen during that time. (050820) A participant who enjoyed exciting rides expressed disappointment. I guess you call it an adventure junkie. I like, amusement parks. I love roller coasters and I got my boyfriend to go to Kings Island with me. We even bought a year pass, which was bad cause COVID hit. And then we couldnt, we only got to use it once. Um, but, uh, our biggest thing we wanted to do before COVID hit and we didnt get to then, and now were waiting till we can, is going zip lining. So, I want to go zip lining. So, even though I have, uh, health problems, my, my son said mom, you cant go on roller coasters because, you know, I have heart problems and so forth. I said, you know, what, if I die, I die, happy doing something I like. ([laughed]160919) Theme 2: Health and Wellbeing The lifestyle changes experienced by the participants forced by the mitigation mandate and protocols also impacted their health and wellbeing. The aspects of health and wellbeing affected were mental/spiritual, medical conditions, and outlook on life. Also, participants perceived that some general and routine parts of life were adversely influenced by changes in lifestyle during the pandemic. To overcome these health and wellbeing challenges, the participant adopted coping mechanisms. Mental/Spiritual Participants pointed out that the effects of mitigation protocols made them feel isolated. it was the frustration that came from the isolation of wanting to go and wanting to do something and make it better, and you couldnt do it there is no substitute for the personal touchIt made me feel cut off. (130108) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 45 Some expressed the feeling of abandonment. You want to feel useful. You want to feel needed. And I think that feeling of theyre too busy for you. They dont have time for you. So, youve got to make your own life. You got to stay active, creative, get out there and live. (100319) The isolation and abandonment led to feelings of depression. the depression of not being able to see your friends and to get out, um, puts a big wall between, how do you pick yourself up when you want to go, and you cant get off, its like the door is locked and I have to stay in here, and everybody else is outside having a good time. (100619) Mental stress was also a common adverse effect shared by the participants. I felt like I was a prisoner. I couldnt see any of our friends I just got really depressed. I craved fresh air. I missed my independence (got tearful) felt like I had no control at all (100713). Also, some participants viewed social distancing, stay-at-home, and mask-wearing infringed on their freedom to do usual activities. I felt like I wasnt able to make, decide what I wanted to do or whether I could, when I want it toit made my whole life, kind of in a sad thing to me, since I am an outgoing person and most of the time and, uh, the older you get, I think the worst it gets you. (050820) Spiritual emptiness was experienced since religious services were stopped. I was a worship leader at a church sang with the church, um, and that had to all stop because not only of the virus, but I have, I might as well say it. I have end-stage renal (failure). Um, Im diabetic, um, just some medical problems, and then the leg (left below- RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 46 knee amputation) didnt help. Um, its hard going out, and then youve got that fear of picking up something. And, um, so just lots of issues. (100619) Medical Conditions Impacted the Most When asked what medical condition was affected the most during the COVID-19 pandemic, one response was, My COPD (chronic obstructive pulmonary condition) because I cant get to the doctor when I need to (231008). Some believed mask-wearing caused or aggravated respiratory illnesses. The mask made chance of getting anything stronger. (050820). While others feel it was a necessary practice to prevent the spread of COVID-19 infection. Well, it didnt bother me. It didnt bother me a bit because I feel like if we want to get rid of it, we gotta follow the house rules and the health laws (231008). Another participant implied a direct impact on health conditions. I guess blood pressure mainly because Im so... kind of on edge all the time it seems like, which isnt good for anybody around me. (100713). Advanced degenerative joint disease primed for surgical interventions postponed due to the mitigation mandate and protocols and personal fear from acquiring the infection made the participant endure debilitating pain. about my shoulders that was giving me pain. I couldnt sleep roll over at night. They hurt and everything. And, uh, I finally got sick enough that I got painkillers and stuff. And so, theyre not bothering me now, but that was terrible too because twice I got ready for surgery and didnt go. And then when they call me to go, it was like one of the first people they called and it was like, no, its a hospital full of people dying. (050820) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 47 Outlook on Life Most participants expressed an optimistic outlook of their health situation and life overall. Acceptance, compliance, and resilience (toughness) are characters that some participants perceived helped them get through the pandemic. Just do it, you know, we cant, dont have a choice. Um, you make the best of what you got. I dont know any other way to put ityou do what you gotta do day by day. Try to make the best of it. (100713) Other participants recognized the need for lifestyle changes but did not allow fear to rule their lives and decide their fate. My whole outlook on life is wow! Im ready to get out there and live again, with or without the pandemic. Its not going to stop me from doing, you know, what I can do. There are limitations, I know, but life looks good. I have a good outlook on life. (100319) Participants expressed awareness that what they lived through and endured are teachable moments that would help them prepare for the next health crisis. I think going through this, this epidemic, all of us have learned what needs to be done and how we need to follow the directions and the rules and cooperate with each other (100619). Some realized and acknowledged that having a negative attitude is not helpful to their health. Oh, I try to keep a positive attitude, and I have days that I dont feel very positive, you know, but I try to keep a positive attitude. I try to keep a smile on my face instead of being a grump all the time and hollering about how bad I feel. I tried to make myself get up and exercise because if I just sit up all the time, I just feel worse. So, Ill get up and walk around through the house, and I messed around like that. (231008) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 48 Trust with their doctors knowledge of the COVID-19 and skills to help participants recover if infected eased the worry, stress, and anxiety in living their lives. I didnt really think about, was I going to get COVID? I thought if I do, and my doctor was so awesome, he gave me, um, confidence from the get-go that even with my health issues, my health was, he felt strong enough and good enough that even if I got it, I would be okay... Thats my faith. And I have a lot of faith, a tremendous amount of faith in my doctors, and they felt we were on the right track and to move forward. (100319) Some recognized that the unexpected challenges imposed by the pandemic made them have a better appreciation of things in their lives. I think with the way COVID-19 hit us so unaware and everything, that we handled it the best we could. I really doBut its getting more back to normal. And my outlook is I appreciate things a little more. I really do. (160919) However, one participant perceived the mandated safety measures as intimidating and controlling. that stay-at-home thing... has made me feel like, is it ever going to stop because theres going to be some people scared to death from now on. And I think when they scare you, they can control you. And I dont like that. I dont like the way that makes me feel. So, I guess at least me not having as much good outlook for my kids in the future as they would have had. (050820) Coping Mechanisms Coping mechanisms were employed to overcome medical, psychological, and physical deterioration. Participants turned to humor and laughter to cope with loneliness. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 49 I think that maintaining good humor and thats not always easy (laughter)Just tried to have good humor (laughed)... you know, just laugh about it if you can. And just know that there is light at the end of the tunnel, and youre getting there. (130108) Entertainment through audio-video streaming on a smartphone was used to help pass the time. I would listen to comedians and so on...entertainment, such as the Red Skelton and old-time comics, Moms Mabley and other groups (130419). Some wrote greeting cards and letters of encouragement to friends and church members to feel useful. I try to every week write at least three cards and send them to people just saying, thinking of you, or, you know, its your birthday happy birthday or whatever, because I feel like were not being able to gather in church were so out of touch and the church family is, you know, it was an important part of my life. (130108) Others noted that telephone use to reach out to friends and family members was still effective in filling out the time. I still call people and talk to people on the phone (020218). Some participants walked in their neighborhood and interacted with neighbors to stay physically active and emotionally and mentally engaged but were also observant of the mitigation protocols during the activity. I would still take walks around the neighborhood with my dog. I saw neighbors up and down the street, and if they would come out and talk, we would visit but keep our distance (100319). Taking up a new hobby using computer research kept the other participants busy. Well, I do genealogy, so I work on my computer on genealogy, and I talk to the kids on there and I like to go back and read history and stuff like that on the computer. I like to research people and research things. And that has been mainly my entertainment because I cant get out of the house, and nobody comes by. (231008) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 50 Theme 3: Access to Health Care Services The participants shared lived experiences elicited common concerns and needs related to accessing health care services during the pandemic. These issues are reflected in the following five sub-themes: appointments; health care needs, interventions, and treatment; pharmacology; support system; and financial limitations. Taken as a whole, the accounts of the participants showed interdependence of these issues. Technology and the mitigation protocol also impacted participants ability to access health care services. Appointments All participants mentioned some degree of difficulty and reservations with keeping and attending medical appointments. Participants cited transportation as one of the main concerns related to accessing health care during the pandemic because of the impact of the mitigation protocol. Those who could not drive even before the pandemic and some who otherwise could drive but due to age-related issues, chronic medical problems, and recent surgical interventions expressed worry due to the uncertainty of not finding anyone to drive them to health-related appointments. Before it was no problem. Just make an appointment, get in the car, drive to it and take care of business... for some reason because of the pandemic, all of a sudden, I was not supposed to drive any (100713). However, participants were able to find paid services to take them to appointments. before the COVID 19 pandemic, I would drive myself to doctors appointments, medical tests, Im very lucky to have a lady who works for me, who is very flexible, and her husband is very good to pitch in too sometimes. And she was able to take me to whatever medical things I had to do in Richmond or wherever and take me to them. (130108) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 51 Participants stated that public transportation continued to operate. ...we have Preble County transport, which takes me to all of my doctor appointments waits with me... brings me home (100619). Some relied on friends to take them to their appointments. I have a friend that takes me all the time to, to my appointments (130419). Others depended on family members. My daughter and her husband took me to all my appointments (231008). Some participants deliberately held off in seeking medical consultation due to fear of being admitted to the hospital or nursing home where chances of acquiring COVID-19 infection are more significant since it is full of people infected by COVID-19. I had a lot of trouble with my shoulders... and I needed them replaced. I was going to do one arm, the left one first, and then the other one, all prepared. They called and canceled because of COVID, and they called back, and they rescheduled it and they canceled it again. And so, while the COVID was going big and everybody was dying, I get a call. I can come in now. And I said, no, Im not going to be the first one to go in. I dont believe in all this COVA stuff, but Im not going to flirt with it either. (050820) One participant experienced punctuality from the physician instead of the usual long waiting time from the scheduled appointments before the pandemic. I tell you, going to the doctor has been so much more convenient, and quick. It seems like when you go now you have a specific appointment. You dont sit in the waiting room for two hours when its time to go in, they take you in your appointments done and your home in the half hour, 45 minutes. And Ive often wondered why couldnt they do that before? (100713) Another experienced difficulty scheduling appointments, including with specialized healthcare providers, during the lockdown. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 52 I took the quickest option I could by having the shots done at the primary care provider, instead of ortho, I would have preferred ortho because of the numbing spray that orthopedic office uses that the primary care physician did not. (180503) Health Care Needs, Interventions, and Treatment The interventions and treatment mentioned by the participants in this study were generally related to declining physical conditions (muscular weakness, decreasing endurance, joint stiffness, joint pain, muscular aches, standing balance deterioration), chronic disease management such as arthritis (knees and back), blood pressure, and gastrointestinal problem. Similar to general medical appointments, everyone experienced varying degrees of difficulty scheduling needed medical interventions and treatments. Most of the participants continued to schedule and kept their appointments for interventions and treatments for joint problems, dental, eyes, and medical conditions. One joint replacement participant expressed disappointment for being unexpectedly discharged on the same day due to the lockdown mandate. I had my first knee operated on my right knee, and while I was on the operating table, Richmond closed the hospital. And so, when I got back to my room, I was going to have one to one and a half days of physical therapy. And when I got there, they threw me on the walker and said, if you can walk from here to this place down here, were sending you home. And so, I had surgery at eight in the morning, and I was home by 10:30 in the afternoon on that first knee, believe me, I wasnt quite ready. (130108) One of the participants, a veteran who spent several weeks in a skilled nursing facility for rehabilitation after hospitalization before being discharged home, expressed frustration from the delay and limited physical therapy treatment. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 53 ...when I went to the nursing home was when it got worse was because I was confined to the room for six weeks, and on my own, ... I did not do any real physical therapy. And... I thought that I would get more physical training and physical fitness... (130419) A participant who has diabetes and received in-clinic hemodialysis, although the scheduled treatment continued uninterrupted, voiced frustration for a particular restriction established for COVID-19 mitigation protocol compliance. ... before the COVID thing. I could take a snack with me to dialysis. Now, were not allowed to do anything like that. So that puts you right on that edge of when I get home, Im just starved (100619). Participants voiced appreciation for receiving rehabilitation interventions and treatment from the home health care program. Physical therapy and occupational therapy have come to me, which I have really appreciated because it kept me from having to drive daily back to Richmond to be with a group. (130108). Also, participants deemed home health care invaluable during the pandemic because it prevented a health issue from having a possible severe consequence. I had a day where my blood pressure went extremely low. Fortunately, I had a healthcare nurse here at that time and called the EMT. I got to the hospital, and I got well. Had she not been here? I dont know. I might not be here today. (100319) The home health nurse served as a bridge between the patient and the primary care physician, reducing the mental stress of calling the physician and scheduling an appointment under the mitigation mandate. I love the communication between home health and the doctors... (the nurse) calls the doctor for me when my blood sugars are high... that allows the doctor to follow it, RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 54 address it and follow up with either an appointment to come in or a phone call that we need to change meds or do whatever intricate part of taking care of me. (100619) Also, the routine in-person visitations of the home health care agencys clinicians provided psychosocial support to the participants. If we hadnt had the people coming in (long pause, trying to hold off tears), wed have gone nuts... its that somebody checking in... you need those persons to know that theres a life out there (100619). Pharmacology In general, the participants expressed that they experienced no disruption in receiving prescribed medications. ...as far as the medications, if I run out, I call them, they call in prescriptions and Id go get it. Its about the same as it was before this pandemic. But at least Im not getting involved with a whole bunch of people (020218). Prescription drugs were picked up at the pharmacy. I continued to get my prescriptions filled at the local CVS. So, and none of that stopped (100319). Some participants received their medications by mail without problems. It hasnt changed immensely. I mean, I get, Ive always gotten my medicines through the mail (130419). Similar to appointments, most of the participants in this study depended on support systems available to secure needed medicines. Im very lucky to have a lady who works for me she was also able to pick up medications (130108). A participant cited that one of the values of home health care nurses during the pandemic was medication management. ... home health care nurse... calls my doctor... when we need to change medications... she is also here to explain medicine changes (100619). This home health care nurses service helped eliminate the possibility of the participants being scheduled for an in-person consultation, reducing the exposure to COVID-19. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 55 Support System As previously mentioned, the participants clearly expressed the significance and value of their support system in facilitating access to services to meet their health care needs. The support system received came from family, friends, church members, club members, home health care clinicians, and the local community groups and services, and it impacted all the facets of participants health and wellbeing. The local public transportation services were relied upon by some participants to get them to their medical appointments. I just call the County and ask them if they can pick me up. And Ive been fortunate that theyve always been able to take care of that for me (100713). The local grocery store calls participants for grocery needs and delivers them. the grocery store has called me at least once a week to see if theres anything they need to deliver. Uh, and so have the other shops. (130108). Friends helped in picking up prescription drugs. ...prescriptions either we pick them up, or friends pick them up for us (100619). Help with shopping was also provided by friends. Since COVID-19, I have a friend that would go and get groceries for me. Also, at the department store. (160919). The home health care services provided immediate intervention and treatment of medical problems. The home health nurse was very handy with me. She has been from the get-go... And she would call and check on me and talk to me from time to time, and I could always call her (050820). Participants also perceived home health rehabilitation to be valuable during the pandemic. Once a week, I had home visits by the occupational therapist and physical therapist, and we worked for about an hour. During those times we do walking, balancing, stretching for physical therapy and tying knots, doing things with my hands, keyboarding, writing with occupational therapy. I had to learn to write again. (100619) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 56 Theme 4: Use of Technology The use of technology (video and phone visits) promoted by medical providers to continue to provide health care services and, at the same time, follow the CDC safety measures is one of the factors that influenced the participants motivation and ability to access health care services. Participants accounts of experiences related to the use of technology during the pandemic revealed that it also had some utility for personal purposes. However, some participants could not participate in telehealth because of the prohibitive costs of digital devices and the necessary internet subscription. Health Care Purposes The participants in this study had mixed sentiments regarding using technology for health care purposes during the pandemic. Some participants deemed the use of remote visits (video or teleconferencing) helpful. One participant expressed, FaceTime, I had two of those with a cardiologist PA (physician assistant), and then I had one with my own personal physician, and those, you know, were quite helpful. Id never done anything like that before (100319). Others stated that remote visits facilitate the accessibility of health care. I think its more convenient, you know, I dont have to worry about having somebody to take me and, you know, bring me back... (020218). Additionally, it made participants feel that someone cared about their health care needs. I at least felt like somebody was listening to any concerns I had rather than having to call and bother the doctor, you know. Cause sometimes you think, well, itll get better, but when they call you, you think, well, I can mention this, actually it gave me a sense that I am being heard. I also knew my doctor was keeping an eye on me and cared about how I was doing. (160919) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 57 It also provided ease of mind since participants were able to reach their health care providers easily. Well, I can get immediate service. I mean, thats immediate service being able to get questions and answers... and I mean, its just like that, you know, thats what I like about it (231008). One participant mentioned that it could compel compliance with exercise. I think a video conference will encourage me to do the exercises (160919). Others resisted and objected to their use, believed that remote visits do not allow healthcare providers to see nuances such as mental stress. I dont like them. I understand the reasoning, why knowing the limited services available, but I dont think you get that one-on-one with your patient. And I think you miss all the cues that are happening around.you dont see the mental stress of a patient. (100619) Some strongly voiced their opposition to video conferences, going so far as declaring it to be worthless. I dont see much good in it at all to tell you the truth... I think its a waste of time and money for people... Get rid of the telehealth stuff, ditch that and just be yourself, just treat them like human beings. You know, we all need somebody. Take an extra five minutes just to chat. (100713) Personal Use Besides health care services access, participants also used internet technology for other life necessities and as a coping mechanism. Some participants expressed interest in and welcomed the use of technology in general. I dont mind the video part of it because I like electronics and everything... Because I had so many other electronic things before this all hit, RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 58 that it, some of it fascinate me to be truthful about that... (050820). The use of social media helped participants reach out to friends alleviating boredom and loneliness. Thank goodness for social media. I can still talk to them (friends), keep up with them that way... dont get to hug them like I used to... and I dont get to see them as often as I used to, but I can communicate with them. (100619) Others used digital devices to keep in touch with family members. Im set up with one of the Echo Shows (Amazon smart audio-video system), and I have a son in Alaska, and most of the time we video talk. And, and so Ive gotten used to that (050820). Some participants did their shopping using the internet to comply with the stay-at-home mandate and mitigation protocols. ... we have been shopping by phone, TV, and then just typing. Yeah, computer... So, weve gone to Krogers Instacart, and they do our shopping and bring it to us (100619). As noted previously, one participant used the internet for a hobby. I do genealogy, so I work on my computer on genealogy, and I talk to the kids on there and I like to go back and read history, and stuff like that on the computer. I like to research people and research things. And that has been mainly my entertainment because I cant get out of the house, and nobody comes by. (231008) Financial Limitations The stay-at-home mandate and mitigation protocols promoted the use of technology to facilitate health care access and delivery (telehealth). However, some participants cited financial limitations as the main barrier to participating in telehealth. Why most people... dont have them, its the expense of them (130419). Also, the costs of internet subscriptions are prohibitive to some participants, and they do not want to use it for anything else, including accessing health RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 59 care services through telehealth. I refuse to use my computer for doc appointment, communication, etc. I pay for the internet for my pleasure not the medical field (231008). Participants Recommendations to Help Improve Access and Delivery of Health Care Services for CDOA in the Next Pandemic When asked for recommendations on how healthcare could be better or best delivered to persons like themselves during the pandemic, the participants provided suggestions covering politics, freedom of choice, finance, transportation, technology, local community program, healthcare professionals, and home health care. Comments regarding politics were related to openness, transparency, and honesty. I much prefer that those in the know, to the best of their abilities, keep politics out of it, keep personal gain out of it, try and get to the bottom of whats going on, figure it out, and then tell us in the meantime, do what you can to keep us from being scared to death, you know, do what you can Number one, be honest and dont say anything, dont go out there and presume this, or assume that, wait till you have the facts. I know thats difficult to come by because things change. (100319) The consensus was that doctors should be leading the dissemination of information and guidance and not the politicians. I think it would be best if the people could have confidence in where our information for this illness would have come from... in my opinion, it comes directly from politicians instead of doctors (050820). The cost of digital devices such as smartphones, tablets, or computers and internet connections also prevented some participants from participating in telehealth. Therefore, the participants recommended financial assistance for digital devices used for accessing health care services. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 60 I dont know... how much it would cost, but it may be an insurance thing. It may be something that if you qualify through insurance, Medicare, or something for the older adults to have a (digital) device, like for example... the home buttons... for emergencies... lifeline units. So, most everybody gets those, and Ive got one. (130419) Some advocated for the establishment of a free transportation program in their local community. Transportation, transportation, mainly, you know, to get these people, to their appointments people need more access to appointments, doctors, you know, and stuff like that. Cause Im sure there are people out there that are not getting their health needs I think that if there was like the little, clinic down here in town, if there was more of those and more accessible for people like me. (020218) In addition to transportation, participants also made other local community program recommendations such as proactive, targeted campaigns and advertisements for CDOA on COVID-19 information updates (mortality and spread of infection rate, the emergence of new variants, vaccination availability, and changes mitigation mandates) and building town clinic. I still, since that time, havent seen much emphasis on my age groups and me being more likely to have serious health problems or death from the disease itself. So, Ive seen less campaign to get seniors involved. I dont know the level of seniors that have done it. Theres been no news releases. I dont know if its good. I dont know if its bad would be nice to be able to inform the public to kind of relate that. And the state knows all of these demographics It would be nice to know that because we dont know were the more likely group aside from frontline workers to die or have serious health conditions from it, then where do we stand? Where do we stand in the mix? I wouldnt want to die RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 61 from it, nor will I want to give it to somebody else. So, it would be to be able to communicate those metrics. (180503) Related to telehealth (technology), participants also suggested incorporating vital signs during videoconferences (remote video visits). I think that the video conference... is very good. I think it should include vital signs since we have the technology. Now, if we can just get it out to people (160919). Furthermore, the participants endorsed an older adult-friendly educational and training program in using digital devices to access health care services. I think you have to work with your clients, help them understand what telehealth is, what to expect, um, what to have ready when youd go through a conference like that, um, be prepared, um, and help have them (100619). Participants advised healthcare providers to be active listeners. Listen to what the persons telling you, I mean the patient, listen (050820). Also, to proactively reach out to patients. I think probably just, maybe going through files and saying who are my patients that might have trouble and might not come to me because of problems and just having maybe the nurses or receptionist just check in and see how are your people and staying on top of being proactive rather than reactive on your end. (130108) Participants suggested that physicians return to making house calls during pandemics. One thing I had heard about that had made me excited that I heard before COVID, but Ive never really seen any results from it. It was about how the doctors were going to start making, uh, house calls again especially ill senior citizens who are in the rural areas. And theres been times when, you know, you feel like youre too sick to go, especially if you cant drive yourself. (160919) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 62 The participants who voiced disfavor for the use of remote visits advocated keeping face-to-face appointments. I want to see my doctor. I want to see my primary care physician than a specialist because he is primary, and hes the one thats going to pick up on, hopefully things before they become a huge problem. And so, I really think its important that those appointments be face to face. (130108) A common sentiment expressed by the participants is related to the value of home health care in meeting their health care needs during the pandemic. ... getting the healthcare workers when you need them sometimes is really hard, and they need to set up something for people like that... the nurse comes out and rehab, something like that to take care of the disabled and the elderly. (231008) Lastly, the participants general advice, to ensure that the health care needs of CDOA like them are addressed and met, was for older adults to be informed, cooperative, and follow the rules. I think going through this epidemic, all of us have learned what needs to be done and how we need to follow the directions and the rules and cooperate with each other. And I think were learning to do that. Its getting easier for people because its becoming part of our life now. So, I think the next time it happens, schools are going to be ready. Hospitals are going to be ready. People are going to be ready. Its not going to be such a shock. Its not going to be, oh, you cant go here, and you cant do this. (100619) Discussion The COVID-19 pandemic abruptly and significantly disrupted the lives of everyone in the world. Compared to the global influenza pandemic, the mortality rate of COVID-19 is higher in the older adults population with medical comorbidities (Petersen et al., 2020). This fact that RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 63 confronted older adults during the 2020 pandemic created stress that affected their mental, emotional, behavioral, physical, and medical conditions (Whitehead & Torossian, 2021). It is reasonable to infer that the combination of multiple pre-existing comorbidities and age-related debilities (physical and cognitive), most older adults who live in rural communities that already face health care challenges, would have more significant difficulties meeting their health care needs during the Covid-19 pandemic (Skoufalos et al., 2017; Tkatch et al., 2017; Yamada et al., 2015). The purpose of this study was to understand the lived experiences of rural CDOA with multiple chronic diseases during the COVID-19 pandemic focusing on meeting their health care needs. Qualitative phenomenology was the research process chosen to understand better participants perceptions of their shared lived experiences during the COVID-19 pandemic. Using Colaizzis phenomenological method for data analysis, this study suggested that the rural CDOA participants considered the impact on mitigation protocol, lifestyle, health and wellbeing, access to health care services, and the use of technology as the main factors that affected their ability to meet their health care needs during the pandemic. A deleterious pattern emerged related to how the stay-at-home and mitigation protocols affected the participants health through deeper dissection of their shared accounts. The feelings of isolation brought about by the mandated safety measures were believed to have caused anxiety and depression, precipitated decreased motivation in physical activity engagement, adversely affected immunology, and exacerbated existing medical conditions. Despite the fear and anxiety drawn from the uncertainty related to the COVID-19 pandemic, the participants in this study were highly compliant in following the recommended safety measures. This characterization reflected the results from Kim and Crimmins' (2020) RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 64 study, which suggested that older adults are more likely to follow safety measures than their younger counterparts. Ironically, this character trait of compliance, particularly related to the stay-at-home mandate and mitigation protocols during the pandemic, contributed to the feeling of isolation, loneliness, and depression. In older adults, emotional and mental stability largely depends on their social connectivity (De Pue et al., 2021). The involuntary disconnection from routine social connections of older adults brought on by the CDCs safety measures mandates resulted in the isolation causing depression. The participants perceived and experienced adverse emotional and mental conditions from social dissociation correlate well with the findings of Santini et al. (2020). These adverse emotional and mental effects of the stay-at-home mandate and mitigation protocols eventually resulted in motivational decline (behavioral) to participate in physical activities. In older adults, especially those with chronic conditions, the absence of physical exertion not only affects the musculoskeletal system but also dramatically diminishes the strength of the immune response (Damiot et al., 2020). Older adults are stereotyped as a vulnerable group of society (Turk & Mcdermott, 2020). Given this, it would be easy to be convinced that their chances of surviving a pandemic are far less in rural communities because of deficient medical and technological infrastructures, insufficient social support systems, and shortage of healthcare providers (Henning-Smith, 2020; Morrow-Howell et al., 2020; Naja & Hamadeh, 2020). However, the shared lived experiences of participants of this study implied that even with the complex challenges that the COVID-19 imposed, in general, they were all able to meet their health care needs. The participants accounts indicated that in addition to their adaptation to COVID-19 challenges, other crucial support systems influenced the ability to meet their health care needs. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 65 These support systems include social connections (family, friends, group affiliation, club memberships), local community programs, and the healthcare system. A common theme that emerged from these support systems based on the participants accounts is the role of technology. Participants shared lived experiences for this study revealed that technology was used for social connections, entertainment, hobbies, and source of information. Recognizing that these support systems are vital to the successful management of rural CDOA health and wellbeing, particularly in times of health crisis such as a pandemic, improving their strength and stability is therefore imperative. Such undertakings should focus on what Chen et al. (2021) described as social, community, and health care system resiliency. Support Systems Social Connections The narrative of participants experiences suggested that it was not only the deeds of driving them to appointments, picking up their prescriptions, helping with home maintenance, and running errands from family members, friends, group constituents, and club organizations that helped with their health and wellbeing but more importantly, it was the social connection. During this pandemic, participants perceived the mandated safety measures caused a cascade of adverse impacts on their emotional, psychological, behavioral, and medical conditions. To alleviate the feelings of isolation, abandonment, and loneliness that lead to depression, anxiety, and disincentive to engage in physical activities, programs that advocate social connections are vital for rural CDOA. A web-based social support group is an example of an action plan under this type of community program (Smith et al., 2020). Older adults can either or both be a member and a mentor within this program. This sort of program encourages older adults to reach out and connect with their peers who are in the same predicament of isolation and loneliness. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 66 Local Community Programs The participants alluded to these types of programs with their recommendations. Specifically, the participants suggested reliable and affordable public transportation; regular, factual public service announcements (PSA) specific to age and the social group delivered by experts (not politicians); and financial assistance and technical support for using technology to access health care services. Transportation. Rural communities in the U.S. faced transportation challenges even before the COVID-19 pandemic (Henning-Smith et al., 2017), and participants in this study described a similar predicament. Some participants shared not being able to rely consistently on family members and friends for transportation due to work, illness, and other life-related issues during the pandemic. The perceptions of participants of this study suggested that the local government and private organizations need to come up with solutions to the transportation problem to help older adult residents make their health care appointments. Reliable and Non-Political Source of Information. Although none of the questions asked during this studys interview were related to politics, some participants voluntarily shared their perceptions of how well or how inadequate the nations response to the COVID-19 pandemic was due to political leadership. Some participants also voiced differing views on experts in the health care department of the government, and this point of view supports the current hyper-partisan state of affairs in the U.S. (Gadarian et al., 2021). The widespread misinformation through social media and TV news outlets has been a factual occurrence permeating everyones lives continuously every day pre-pandemic, which increased during COVID-19 (Soto-Perez-de-Celis, 2020). Also, it is posited that older adults are likely to share misinformation with their friends and family to strengthen common political beliefs RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 67 (Roozenbeek et al., 2020). Since participants in this study shared their use of social media to connect with friends and family, it is reasonable to assume that they were exposed to misinformation disseminated on the internet related to COVID-19. Given the complex nature of human psychology, behavior, and belief system, the task of educating people without the perception of bias would be a tremendous undertaking. However, as suggested by the participants lived experiences in this study, reliable information is crucial in health care management in times of a pandemic. A non-partisan community-based program run by known health care experts providing evidence-based information would help improve rural CDOA health care literacy and combat misinformation. Such trustworthy information can be spread in the community through PSA (TV, radio, internet, newspaper). Technology. Another vital piece of information that emerged from the shared lived experiences of participants in this study was that issues related to technology use are no longer due to fear (Lee et al., 2019). In fact, all participants welcomed the use of technology for a variety of purposes. Some participants described using social media to connect with friends and family, and others streamed music and videos for entertainment. They took advantage of technologys convenience during the pandemic, such as online shopping. It appears that older adults are no longer intimidated by technology that participants stated using it for research as a hobby. None of the participants mentioned connectivity problems, which suggests that, at least for these rural communities, the needed digital communication infrastructures are in place. The participants openness to the use of technology in this study supports the suggestions that most older adults embrace its ubiquitous use for health care access (LeRouge et al., 2014). The use of technology is an essential tool, especially for older adults, to maintain medical, mental, and emotional health during a pandemic. Technologies such as telehealth monitoring RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 68 tablets, wearable and implanted digital devices for monitoring (vital signs, blood glucose level), and delivering medication doses (insulin pump) are beneficial and acceptable to most older adults (Charness et al., 2016). The use of remote or virtual visits has increased across geographic demographics in older adults during the COVID-19 pandemic (Chu et al., 2021). Although this study elicited varied perspectives towards remote visits, most participants availed of its use to meet their health care needs. Therefore, it is worth pursuing and improving upon since preliminary studies suggest it can be an effective modality in health care services during the COVID-19 pandemic (Doraiswamy et al., 2021). Using tablets (iPad Air and Samsung Galaxy) and an App, Andrews et al. (2019) suggested that digital technologies can effectively improve and maintain the mental health and wellbeing of older adults. The participants in this study used digital devices (smartphones, computers, tablets, and smart TVs) for entertainment (streaming audio and video content), social media (Facebook), and a hobby (genealogy) as an effective diversion to combat loneliness and depression. The primary barrier mentioned related to the use of technology is the financial limitation affording the devices and internet subscriptions. For this reason, the participants recommended the establishment of a financial assistance program to help them acquire the necessary digital devices and web connections to participate in telehealth services. Also, training programs for telehealth use that are sensitive to the learning characteristics of older adults should be developed. This process will help attract more interest from older adults in using technology for health care access (Andrews et al., 2019). RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 69 Health Care System As discussed previously, most rural CDOA faces more significant health care management barriers because of pre-existing exacerbating factors in addition to the mitigation mandates during the COVID-19 pandemic. Absent a perseverative character, help from social circles (family members, friends, group, clubs), and the use of technology, this studys participants shared lived experiences suggested that health care system access during the pandemic would have been almost unattainable. Participants perceived home health care services, physician house calls, establishing town clinics, and proactive delivery of services from healthcare providers are programs that could help ensure their health care needs are met. Home Health Care Service. Participants responses to questions related to their health care management revealed their appreciation of the value of home health care services, particularly during the pandemic. Some participants even viewed the visitations from home health care practitioners as a source of social connection. Nevertheless, some participants expressed frustrating viewpoints related to replacing in-person visits with remote visits and delayed services. On April 30, 2020, the Center for Medicare and Medicaid Services issued an emergency policy that waived the standard homebound status criteria (Bekelman et al., 2020). It provided an opportunity for physicians to become more proactive in prescribing home health care interventions, including nursing, physical therapy, occupational therapy, speech therapy, and medical social worker services as appropriate to their Medicare beneficiary patients. However, a significant drop in home health care services was experienced during the pandemic, especially during the early period of 2020 (Jones & Bowles, 2020; Sama et al., 2021). There were several reasons for such dramatic reduction, including (Jones & Bowles, 2020): RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 70 the recent introduction of the use of Patient-Driven Grouping Models (PDGM) in the reimbursement system insufficient supply of personal protective equipment (PPE) and COVID-19 testing paraphernalia decreased referrals due to fear of acquisition and spreading of COVID-19 infection, especially during rises in transmission rate and the emergence of new variance non-reimbursement of telehealth services Before the pandemic, home health care agencies (HHCA) struggled to adapt to the newly enforced reimbursement system. At the behest of the Bipartisan Budget Act of 2018, the Center for Medicare and Medicaid Services (CMS) made changes in determining the reimbursement for home health services, and on January 1, 2020, PDGM became effective (CMS, 2020). The episode of care, which was 60 days, was reduced to 30 days and the number of rehabilitation (PT, OT, ST) visits no longer determines the amount of reimbursement (CMS, 2020). For HHCA, since rehabilitation disciplines were the driving services for reimbursement, the introduction of PDGM meant a significant revenue reduction while adjusting to its rule (Ankuda et al., 2020). HHCA, which failed to adjust, inevitably stopped operations. The consequence is limited HHC agency availability during the COVID-19 pandemic. Early in the COVID-19 pandemic, health care providers, including HHCA, experienced a severe shortage of PPE and testing tools (Cohen & Rodgers, 2020; McMahon et al., 2020). Also, the U.S. experienced COVID-19 infection resurgence, and the world was exposed to new variances from mid- 2020 to the early part of 2021 (Abdool Karim & de Oliveira, 2021; Monod et al., 2021). The shortage of PPE and testing kits, the resurgence of infections, and the emergence of new variances of the COVID-19, promoted fear in the health care sphere of RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 71 influence, including patients and health care providers alike, which resulted in refusals and cancellations of home health care services (Jones & Bowles, 2020). The combination of widespread fear and compliance with the mitigation mandate incited and motivated the use of telehealth (Doraiswamy et al., 2020). However, since HHC agencies are already struggling with significant reductions in revenue, adding a service that does not qualify for payment is nonviable (Jones & Bowles, 2020). Home health care was viewed as a valuable and essential support system by the participants in this study to meet their health care needs during the pandemic. However, this pandemic showed that some barriers prevent older adults, including rural CDOA, from receiving home health care services. Efforts should be made in earnest to address the problems previously enumerated to ensure that rural CDOA will have uninterrupted access to home health care services in the next pandemic. Study Limitations This study presents at least two limitations. First, there is no consensus on what defines a rural community (Hawley et al., 2016). The definition used for the rural community in this study is narrow and can only be applied to similar populations. More remote and smaller rural communities would logically have more challenges related to local government funding, available health care workers, and public and private health care and technology infrastructure. Second, the participants are entirely composed of non-Hispanic Caucasians. Since racial health disparities exist (Laurencin & McClinton, 2020), the results of this study cannot be generalized to more diverse rural CDOA minorities. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 72 Implications for Future Research Studies including this one suggested that the safety measures recommended by health care authorities can exacerbate older adults medical, mental, behavioral, emotional, and physical conditions, as well as causing it to spiral into a vicious cycle (Lebrasseur et al., 2021; Santini et al., 2020; Whitehead & Torossian, 2020). It would be reasonable and beneficial to pursue research studies about intervention programs that can effectively prevent the health and wellbeing of older adults from declining during a pandemic. Inactivity, which is one of the negative consequences of the COVID-19 pandemic, has detrimental effects on older adults physical and physiological systems (Damiot et al., 2021). One crucial source of beneficial exercises and functional activities for older adults is physical therapy provided by home health care services. A research study designed to understand the perceptions of rural CDOA on the effects of home health care physical therapy interventions on their overall health and wellbeing during the pandemic would be a worthwhile project. Although participants of this study had mixed feelings about remote visits, particularly related to home health physical therapy, it is worth exploring how to improve acceptance of virtual physical therapy visits among older adults. Pre-pandemic and pandemic studies have suggested that older adults use of technology has steadily increased (Charness et al., 2016; Chu et al., 2021; Doraiswamy et al., 2021; Lee et al., 2019; Morrow-Howell et al., 2020; Vaportzis et al., 2017). It is reasonable to anticipate that if more studies demonstrate simple and effective use of remote visits for physical therapy as an adjunct to in-person sessions, all older adults will embrace its use. A follow-up study could be designed to ascertain the safety and effectiveness of specific physical therapy programs for remote visits. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 73 Another area for future research is how rural CDOA minorities with multiple chronic medical diseases meet their health care needs during the COVID-19 pandemic. A study suggested that a large number of essential workers who were ordered to continue working are from the minority group of the population (Dorn et al., 2020). McCormack et al. (2020) reported that families of these essential workers have at least one member of 65 years old and older. It would be beneficial to find out how the COVID-19 pandemic affected the health and wellbeing of rural CDOA minority care recipients under the stay-at-home mandate and mitigation protocols compared to the participants of this study. Conclusion The shared lived experiences of rural CDOA participants in this study suggest that despite their vulnerabilities, they were adaptable and maintained a positive outlook on life in the face of a pandemic. In addition to tough personal characteristics, their resiliency also depended on the integrity and efficiency of support systems coming from local social structures (family, friends, groups, church, and clubs), community resources (public transportation, grocery and restaurant delivery services, meals-on-wheels), and health care programs (home health care). Programs designed to augment these support systems and assist in acquiring digital devices and internet connections would help the rural CDOA be better prepared to overcome challenges in this pandemic and the next. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 74 References Abdool Karim, S. S., & de Oliveira, T. (2021). New SARS-CoV-2 VariantsClinical, Public Health, and Vaccine Implications. New England Journal of Medicine, 384(19), 1866 1868. https://doi.org/10.1056/NEJMc2100362 Abedi, V., Olulana, O., Avula, V., Chaudhary, D., Khan, A., Shahjouei, S., Li, J., & Zand, R. (2020). Racial, economic, and health inequality and COVID-19 infection in the United States. Journal of Racial and Ethnic Health Disparities. https://doi.org/10.1007/s40615020-00833-4 Andrews, J. A., Brown, L. J., Hawley, M. S., & Astell, A. J. (2019). Older Adults Perspectives on Using Digital Technology to Maintain Good Mental Health: Interactive Group Study. Journal of Medical Internet Research, 21(2), e11694. https://doi.org/10.2196/11694 Ankuda, C. K., Leff, B., Ritchie, C. S., Rahman, O., Ferreira, K. B., BollensLund, E., & Ornstein, K. A. (2020). Implications of 2020 Skilled Home Healthcare Payment Reform for Persons with Dementia. Journal of the American Geriatrics Society, 68(10), 2303 2309. https://doi.org/10.1111/jgs.16654 Bekelman, J. E., Emanuel, E. J., & Navathe, A. S. (2020). Outpatient Treatment at Home for Medicare Beneficiaries During and After the COVID-19 Pandemic. JAMA, 324(1), 21. https://doi.org/10.1001/jama.2020.9017 Berman, M. A., Guthrie, N. L., Edwards, K. L., Appelbaum, K. J., Njike, V. Y., Eisenberg, D. M., & Katz, D. L. (2018). Change in glycemic control with use of a digital therapeutic in adults with type 2 diabetes: Cohort Study. JMIR Diabetes, 3(1), e4. https://doi.org/10.2196/diabetes.9591 Birks, M., Chapman, Y., & Francis, K. (2008). Memoing in qualitative research: Probing data RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 75 and processes. Journal of Research in Nursing, 13(1), 68-75. doi: 10.1177/1744987107081254 Bolin, J. N., Bellamy, G. R., Ferdinand, A. O., Vuong, A. M., Kash, B. A., Schulze, A., & Helduser, J. W. (2015). Rural Healthy People 2020: New decade, same challenges. The Journal of Rural Health, 31(3), 326333. https://doi.org/10.1111/jrh.12116 Cafazzo, J. A. (2019). A Digital-First Model of Diabetes Care. Diabetes Technology & Therapeutics, 21(S2), S2-52-S2-58. https://doi.org/10.1089/dia.2019.0058 Centers for Disease Control and Prevention. (2020). CDC newsroom: First travel-related case of 2019 novel coronavirus detected in the United States. https://www.cdc.gov/media/releases/2020/p0121-novel-coronavirus-travel-case.html Centers for Disease Control and Prevention. (2020). CDC COVID data tracker: United States COVID-19 cases and deaths by state. https://covid.cdc.gov/covid-datatracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019ncov%2Fcases-updates%2Fcases-in-us.html#cases_casesinlast7days Centers for Disease Control and Prevention. (2020). Duration of isolation and precautions for adults with COVID-19. Centers for Disease Control and Prevention. (2020). Older Adults and COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html Chang, A. Y., Skirbekk, V. F., Tyrovolas, S., Kassebaum, N. J., & Dieleman, J. L. (2019). Measuring population ageing: An analysis of the Global Burden of Disease Study 2017. The Lancet Public Health, 4(3), e159e167. https://doi.org/10.1016/S24682667(19)30019-2 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 76 Charness, N., Best, R., & Evans, J. (2016). Supportive home health care technology for older adults: Attitudes and implementation. Gerontechnology, 15(4), 233242. https://doi.org/10.4017/gt.2016.15.4.006.00 Chen, A. T., Ge, S., Cho, S., Teng, A. K., Chu, F., Demiris, G., & Zaslavsky, O. (2021). Reactions to COVID-19, information and technology use, and social connectedness among older adults with pre-frailty and frailty. Geriatric Nursing, 42(1), 188195. https://doi.org/10.1016/j.gerinurse.2020.08.001 Chesser, A. K., Keene Woods, N., Smothers, K., & Rogers, N. (2016). Health literacy and older adults: A systematic review. Gerontology and Geriatric Medicine, 2, 233372141663049. https://doi.org/10.1177/2333721416630492 Chin, J., Payne, B., Gao, X., Conner-Garcia, T., Graumlich, J. F., Murray, M. D., Morrow, D. G., & Stine-Morrow, E. A. L. (2015). Memory and comprehension for health information among older adults: Distinguishing the effects of domain-general and domain-specific knowledge. Memory, 23(4), 577589. https://doi.org/10.1080/09658211.2014.912331 Chopik, W. J. (2016). The Benefits of Social Technology Use Among Older Adults Are Mediated by Reduced Loneliness. Cyberpsychology, Behavior, and Social Networking, 19(9), 551556. https://doi.org/10.1089/cyber.2016.0151 Chu, C., Cram, P., Pang, A., Stamenova, V., Tadrous, M., & Bhatia, R. S. (2021). Rural Telemedicine Use Before and During the COVID-19 Pandemic: Repeated Crosssectional Study. Journal of Medical Internet Research, 23(4), e26960. https://doi.org/10.2196/26960 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 77 Cohen, J., & Rodgers, Y. van der M. (2020). Contributing factors to personal protective equipment shortages during the COVID-19 pandemic. Preventive Medicine, 141, 106263. https://doi.org/10.1016/j.ypmed.2020.106263 Cottrell, R. R., & McKenzie, J. F. (2011). Health promotion and education research methods: Using the five-chapter thesis/dissertation model (2nd ed). Jones and Bartlett Publishers. Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry & research design: Choosing among five approaches (4th ed.). SAGE. Damiot, A., Pinto, A. J., Turner, J. E., & Gualano, B. (2020). Immunological Implications of Physical Inactivity among Older Adults during the COVID-19 Pandemic. Gerontology, 66(5), 431438. https://doi.org/10.1159/000509216 Davidsen, A. S. (2013). Phenomenological approaches in psychology and health sciences. Qualitative Research in Psychology, 10(3), 318-339. doi: DeCuir-Gunby, J. T., Marshall, P.L., & McCulloch, A. W. (2010). Developing and using a codebook for the analysis of interview data: An example from a professional development research project. Field Methods, 23(2):136-155. doi:10.1177/1525822X10388468 DeJonckheere, M., & Vaughn, L. M. (2019). Semistructured interviewing in primary care research: A balance of relationship and rigour. Family Medicine and Community Health, 7(2), e000057. https://doi.org/10.1136/fmch-2018-000057 De Pue, S., Gillebert, C., Dierckx, E., Vanderhasselt, M.-A., De Raedt, R., & Van den Bussche, E. (2021). The impact of the COVID-19 pandemic on wellbeing and cognitive functioning of older adults. Scientific Reports, 11(1), 4636. https://doi.org/10.1038/s41598-021-84127-7 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 78 Doraiswamy, S., Abraham, A., Mamtani, R., & Cheema, S. (2020). Use of Telehealth During the COVID-19 Pandemic: Scoping Review. Journal of Medical Internet Research, 22(12), e24087. https://doi.org/10.2196/24087 Doraiswamy, S., Jithesh, A., Mamtani, R., Abraham, A., & Cheema, S. (2021). Telehealth Use in Geriatrics Care during the COVID-19 PandemicA Scoping Review and Evidence Synthesis. International Journal of Environmental Research and Public Health, 18(4), 1755. https://doi.org/10.3390/ijerph18041755 Dorn, A. van, Cooney, R. E., & Sabin, M. L. (2020). COVID-19 exacerbating inequalities in the US. The Lancet, 395(10232), 12431244. https://doi.org/10.1016/S0140-6736(20)30893X Douglas, M., Katikireddi, S. V., Taulbut, M., McKee, M., & McCartney, G. (2020). Mitigating the wider health effects of covid-19 pandemic response. BMJ, m1557. https://doi.org/10.1136/bmj.m1557 Elliot, V. (2018). Thinking about the coding process in qualitative data analysis. The Qualitative Report, 23(11), 2850-2861. https://nsuworks.nova.edu/cgi/viewcontent.cgi?article=3560&context=tqr Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine, 382(21), 20492055. https://doi.org/10.1056/NEJMsb2005114 Fischer, S. H., David, D., Crotty, B. H., Dierks, M., & Safran, C. (2014). Acceptance and use of health information technology by community-dwelling elders. International Journal of Medical Informatics, 83(9), 624635. https://doi.org/10.1016/j.ijmedinf.2014.06.005 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 79 Gadarian, S. K., Goodman, S. W., & Pepinsky, T. B. (2021). Partisanship, health behavior, and policy attitudes in the early stages of the COVID-19 pandemic. PLOS ONE, 16(4), e0249596. https://doi.org/10.1371/journal.pone.0249596 Galea, S., Merchant, R. M., & Lurie, N. (2020). The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA Internal Medicine, 180(6), 817. https://doi.org/10.1001/jamainternmed.2020.1562 Gellis, Z. D., Kenaley, B., McGinty, J., Bardelli, E., Davitt, J., & Ten Have, T. (2012). Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial. The Gerontologist, 52(4), 541552. https://doi.org/10.1093/geront/gnr134 Gordon, N. P., & Hornbrook, M. C. (2018). Older adults readiness to engage with eHealth patient education and self-care resources: A cross-sectional survey. BMC Health Services Research, 18(1), 220. https://doi.org/10.1186/s12913-018-2986-0 Haffajee, R. L., & Mello, M. M. (2020). Thinking Globally, Acting LocallyThe U.S. Response to Covid-19. New England Journal of Medicine, 382(22), e75. https://doi.org/10.1056/NEJMp2006740 Hawley, L. R., Koziol, N. A., Bovaird, J. A., McCormick, C. M., Welch, G. W., Arthur, A. M., & Bash, K. (2016). Defining and Describing Rural: Implications for Rural Special Education Research and Policy. Rural Special Education Quarterly, 35(3), 311. https://doi.org/10.1177/875687051603500302 Henning-Smith, C. (2020). The Unique Impact of COVID-19 on Older Adults in Rural Areas. Journal of Aging & Social Policy, 32(45), 396402. https://doi.org/10.1080/08959420.2020.1770036 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 80 Henderson, R., & Rheault, W. (2004). Appraising and incorporating qualitative research in evidence-based practice. Journal of Physical Therapy Education, 18(3), 35-40. Retrieved from https://doi.org/10.1097/00001416-200410000-00005 Huremovi, D. (2019). Brief History of Pandemics (Pandemics Throughout History). In D. Huremovi (Ed.), Psychiatry of Pandemics (pp. 735). Springer International Publishing. https://doi.org/10.1007/978-3-030-15346-5_2 Jackson, C., Vynnycky, E., & Mangtani, P. (2010). Estimates of the Transmissibility of the 1968 (Hong Kong) Influenza Pandemic: Evidence of Increased Transmissibility Between Successive Waves. American Journal of Epidemiology, 171(4), 465478. https://doi.org/10.1093/aje/kwp394 Jones, C. D., & Bowles, K. H. (2020). Emerging Challenges and Opportunities for Home Health Care in the Time of COVID-19. Journal of the American Medical Directors Association, 21(11), 15171518. https://doi.org/10.1016/j.jamda.2020.09.018 Kadam, R. A. (2017). Informed consent process: A step further towards making it meaningful! Perspectives in Clinical Research, 8(3), 107112. https://doi.org/10.4103/picr.PICR_147_16 Kaufman, N., & Khurana, I. (2016). Using Digital Health Technology to Prevent and Treat Diabetes. Diabetes Technology & Therapeutics, 18(S1), S-56-S-68. https://doi.org/10.1089/dia.2016.2506 Kim, J. K., & Crimmins, E. M. (2020). How does age affect personal and social reactions to COVID-19: Results from the national Understanding America Study. PLOS ONE, 15(11), e0241950. https://doi.org/10.1371/journal.pone.0241950 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 81 Korstjens, I., & Moser, A. (2018). Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. European Journal of General Practice, 24(1), 120124. https://doi.org/10.1080/13814788.2017.1375092 Lasry, A., Kidder, D., Hast, M., Poovey, J., Sunshine, G., Winglee, K., Zviedrite, N., Ahmed, F., Ethier, K. A., CDC Public Health Law Program, New York City Department of Health and Mental Hygiene, Louisiana Department of Health, Public Health Seattle & King County, San Francisco COVID-19 Response Team, Alameda County Public Health Department, San Mateo County Health Department, Marin County Division of Public Health, CDC Public Health Law Program, Clodfelter, C., Willis, M. (2020). Timing of Community Mitigation and Changes in Reported COVID-19 and Community Mobility Four U.S. Metropolitan Areas, February 26April 1, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(15), 451457. https://doi.org/10.15585/mmwr.mm6915e2 Laurencin, C. T., & McClinton, A. (2020). The COVID-19 Pandemic: A Call to Action to Identify and Address Racial and Ethnic Disparities. Journal of Racial and Ethnic Health Disparities, 7(3), 398402. https://doi.org/10.1007/s40615-020-00756-0 Lebrasseur, A., Fortin-Bdard, N., Lettre, J., Raymond, E., Bussires, E.-L., Lapierre, N., Faieta, J., Vincent, C., Duchesne, L., Ouellet, M.-C., Gagnon, E., Tourigny, A., Lamontagne, M.-., & Routhier, F. (2021). Impact of the COVID-19 Pandemic on Older Adults: Rapid Review. JMIR Aging, 4(2), e26474. https://doi.org/10.2196/26474 Laverty, S.M. (2003). Hermeneutic phenomenology and phenomenology: A comparison of historical and methodological considerations. International Journal of Qualitative Methods, 2(3), 21-35. https://doi.org/10.1177/160940690300200303 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 82 Lee, C. C., Czaja, S. J., Moxley, J. H., Sharit, J., Boot, W. R., Charness, N., & Rogers, W. A. (2019). Attitudes Toward Computers Across Adulthood From 1994 to 2013. The Gerontologist, 59(1), 2233. https://doi.org/10.1093/geront/gny081 LeRouge, C., Van Slyke, C., Seale, D., & Wright, K. (2014). Baby Boomers Adoption of Consumer Health Technologies: Survey on Readiness and Barriers. Journal of Medical Internet Research, 16(9), e200. https://doi.org/10.2196/jmir.3049 Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., Xia, L., Liu, Z., Yang, J., & Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790e798. https://doi.org/10.1016/S2214-109X(20)30204-7 Lum, H. D., Nearing, K., Pimentel, C. B., Levy, C. R., & Hung, W. W. (2020). Anywhere to Anywhere: Use of Telehealth to Increase Health Care Access for Older, Rural Veterans. Public Policy & Aging Report, 30(1), 1218. https://doi.org/10.1093/ppar/prz030 Manafo, E., & Wong, S. (2012). Health literacy programs for older adults: A systematic literature review. Health Education Research, 27(6), 947960. https://doi.org/10.1093/her/cys067 McCormack, G., Avery, C., Spitzer, A. K.-L., & Chandra, A. (2020). Economic vulnerability of households with essential workers. JAMA, 324(4), 388. https://doi.org/10.1001/jama.2020.11366 McMahon, D. E., Peters, G. A., Ivers, L. C., & Freeman, E. E. (2020). Global resource shortages during COVID-19: Bad news for low-income countries. PLOS Neglected Tropical Diseases, 14(7), e0008412. https://doi.org/10.1371/journal.pntd.0008412 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 83 Merro-Jaffe, I. (2011). "Is that what I said?" Interview transcript approval by participants: An aspect of ethics in qualitative research. International Journal of Qualitative Methods, 10(3), 231-247. https://doi.org/10.1177/160940691101000304 Mesa Vieira, C., Franco, O. H., Gmez Restrepo, C., & Abel, T. (2020). COVID-19: The forgotten priorities of the pandemic. Maturitas, 136, 3841. https://doi.org/10.1016/j.maturitas.2020.04.004 Mesk, B., Drobni, Z., Bnyei, ., Gergely, B., & Gyrffy, Z. (2017). Digital health is a cultural transformation of traditional healthcare. MHealth, 3, 3838. https://doi.org/10.21037/mhealth.2017.08.07 Monod, M., Blenkinsop, A., Xi, X., Hebert, D., Bershan, S., Tietze, S., Baguelin, M., Bradley, V. C., Chen, Y., Coupland, H., Filippi, S., Ish-Horowicz, J., McManus, M., Mellan, T., Gandy, A., Hutchinson, M., Unwin, H. J. T., van Elsland, S. L., Vollmer, M. A. C., on behalf of the Imperial College COVID-19 Response Team. (2021). Age groups that sustain resurging COVID-19 epidemics in the United States. Science, 371(6536), eabe8372. https://doi.org/10.1126/science.abe8372 Moser, A., & Korstjens, I. (2018). Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. European Journal of General Practice, 24(1), 9 18. https://doi.org/10.1080/13814788.2017.1375091 Morse, J. M. (2015). Analytic Strategies and Sample Size. Qualitative Health Research, 25(10), 13171318. https://doi.org/10.1177/1049732315602867 Morrow-Howell, N., Galucia, N., & Swinford, E. (2020). Recovering from the COVID-19 Pandemic: A Focus on Older Adults. Journal of Aging & Social Policy, 19. https://doi.org/10.1080/08959420.2020.1759758 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 84 Naja, F., & Hamadeh, R. (2020). Nutrition amid the COVID-19 pandemic: A multi-level framework for action. European Journal of Clinical Nutrition. https://doi.org/10.1038/s41430-020-0634-3 Omer, S. B., Malani, P., & del Rio, C. (2020). The COVID-19 Pandemic in the US: A Clinical Update. JAMA. https://doi.org/10.1001/jama.2020.5788 Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533544. https://doi.org/10.1007/s10488-013-0528-y Parodi, S. M., & Liu, V. X. (2020). From Containment to Mitigation of COVID-19 in the US. JAMA, 323(15), 1441. https://doi.org/10.1001/jama.2020.3882 Petersen, E., Koopmans, M., Go, U., Hamer, D. H., Petrosillo, N., Castelli, F., Storgaard, M., Al Khalili, S., & Simonsen, L. (2020). Comparing SARS-CoV-2 with SARS-CoV and influenza pandemics. The Lancet Infectious Diseases, 20(9), e238e244. https://doi.org/10.1016/S1473-3099(20)30484-9 Phillips-Pula, L., Strunk, J., & Pickler, R.H. (2011). Understanding phenomenological approaches to data analysis. Journal of Pedicatric Health Care, 25, 67-71. https://doi.org/10.1016/j.pedhc.2010.09.004 Quinn, S. C., & Kumar, S. (2014). Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 12(5), 263273. https://doi.org/10.1089/bsp.2014.0032 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 85 Raghupathi, W., & Raghupathi, V. (2018). An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health. International Journal of Environmental Research and Public Health, 15(3), 431. https://doi.org/10.3390/ijerph15030431 Reher, D., & Requena, M. (2018). Living Alone in Later Life: A Global Perspective: Living Alone in Later Life. Population and Development Review, 44(3), 427454. https://doi.org/10.1111/padr.12149 Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K. W., and the Northwell COVID-19 Research Consortium, Barnaby, D. P., Becker, L. B., Chelico, J. D., Cohen, S. L., Cookingham, J., Coppa, K., Diefenbach, M. A., Dominello, A. J., Duer-Hefele, J., Falzon, L., Gitlin, J., Hajizadeh, N., Zanos, T. P. (2020). Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA, 323(20), 2052. https://doi.org/10.1001/jama.2020.6775 Roozenbeek, J., Schneider, C. R., Dryhurst, S., Kerr, J., Freeman, A. L. J., Recchia, G., van der Bles, A. M., & van der Linden, S. (2020). Susceptibility to misinformation about COVID-19 around the world. Royal Society Open Science, 7(10), 201199. https://doi.org/10.1098/rsos.201199 Roberts, K., Dowell, A., & Nie, J.-B. (2019). Attempting rigour and replicability in thematic analysis of qualitative research data; a case study of codebook development. BMC Medical Research Methodology, 19(1), 66. https://doi.org/10.1186/s12874-019-0707-y Sama, S. R., Quinn, M. M., Galligan, C. J., Karlsson, N. D., Gore, R. J., Kriebel, D., Prentice, J. C., Osei-Poku, G., Carter, C. N., Markkanen, P. K., & Lindberg, J. E. (2021). Impacts of RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 86 the COVID-19 Pandemic on Home Health and Home Care Agency Managers, Clients, and Aides: A Cross-Sectional Survey, March to June, 2020. Home Health Care Management & Practice, 33(2), 125129. https://doi.org/10.1177/1084822320980415 Santini, Z. I., Jose, P. E., York Cornwell, E., Koyanagi, A., Nielsen, L., Hinrichsen, C., Meilstrup, C., Madsen, K. R., & Koushede, V. (2020). Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. The Lancet Public Health, 5(1), e62e70. https://doi.org/10.1016/S2468-2667(19)30230-0 Shereen, M. A., Khan, S., Kazmi, A., Bashir, N., & Siddique, R. (2020). COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. Journal of Advanced Research, 24, 9198. https://doi.org/10.1016/j.jare.2020.03.005 Skoufalos, A., Clarke, J. L., Ellis, D. R., Shepard, V. L., & Rula, E. Y. (2017). Rural Aging in America: Proceedings of the 2017 Connectivity Summit. Population Health Management, 20(S2), S-1-S-10. https://doi.org/10.1089/pop.2017.0177 Sloan, A. & Bowe, Brian (2014). Phenomenology and hermeneutic phenomenology: The philosophy, the methodologies and using hermeneutic phenomenology to investigate lecturers' experiences of curriculum design. Quality & Quantity,.48(3), 1291-1303. https://doi.org/10.1007/s11135-013-9835-3 Smith, M. L., Steinman, L. E., & Casey, E. A. (2020). Combatting Social Isolation Among Older Adults in a Time of Physical Distancing: The COVID-19 Social Connectivity Paradox. Frontiers in Public Health, 8, 403. https://doi.org/10.3389/fpubh.2020.00403 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 87 Soto-Perez-de-Celis, E. (2020). Social media, ageism, and older adults during the COVID-19 pandemic. EClinicalMedicine, 2930, 100634. https://doi.org/10.1016/j.eclinm.2020.100634 Steinman, M. A., Perry, L., & Perissinotto, C. M. (2020). Meeting the Care Needs of Older Adults Isolated at Home During the COVID-19 Pandemic. JAMA Internal Medicine, 180(6), 819. https://doi.org/10.1001/jamainternmed.2020.1661 Stossel, L.M., Segar, M., Gilatto, P., Fallar, R., & Karani, R. (2012). Readability of patient education materials at the point of care. Journal of General Internal Medicine, 27(9), 1165-1170. doi: 10.1007/s11606-012-2046-0 Sutton, J., & Austin, Z. (2015). Qualitative Research: Data Collection, Analysis, and Management. The Canadian Journal of Hospital Pharmacy, 68(3). https://doi.org/10.4212/cjhp.v68i3.1456 Tavares-Jnior, J. W. L., de Souza, A. C. C., Alves, G. S., Bonfadini, J. de C., Siqueira-Neto, J. I., & Braga-Neto, P. (2019). Cognitive assessment tools for screening older adults with low levels of education: A critical review. Frontiers in Psychiatry, 10, 878. https://doi.org/10.3389/fpsyt.2019.00878 Thorpe, J. M., Thorpe, C. T., Kennelty, K. A., & Pandhi, N. (2011). Patterns of perceived barriers to medical care in older adults: A latent class analysis. BMC Health Services Research, 11(1), 181. https://doi.org/10.1186/1472-6963-11-181 Tkatch, R., Musich, S., MacLeod, S., Kraemer, S., Hawkins, K., Wicker, E. R., & Armstrong, D. G. (2017). A qualitative study to examine older adults perceptions of health: Keys to aging successfully. Geriatric Nursing, 38(6), 485490. https://doi.org/10.1016/j.gerinurse.2017.02.009 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 88 Tsai, J., & Wilson, M. (2020). COVID-19: A potential public health problem for homeless populations. The Lancet Public Health, 5(4), e186e187. https://doi.org/10.1016/S24682667(20)30053-0 Turk, M. A., & McDermott, S. (2020). The COVID-19 pandemic and people with disability. Disability and Health Journal, 13(3), 100944. https://doi.org/10.1016/j.dhjo.2020.100944 U.S. Census Bureau. (2010). Rural America. https://gisportal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d13 8cb014711e01 U.S. Department of Health and Human Services. (2013). Health information privacy: Summary of the HIPAA privacy rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html U.S. Department of Homeland Security, Cybersecurity & Infrastructure Security Agency. (2020). Advisory memorandum on identification of essential critical infrastructure workers during COVID-19 response. https://www.cisa.gov/sites/default/files/publications/Version_3.0_CISA_Guidance_on_Es sential_Critical_Infrastructure_Workers_1.pdf van Houwelingen, C. T., Ettema, R. G., Antonietti, M. G., & Kort, H. S. (2018). Understanding Older Peoples Readiness for Receiving Telehealth: Mixed-Method Study. Journal of Medical Internet Research, 20(4), e123. https://doi.org/10.2196/jmir.8407 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 89 Vaportzis, E., Giatsi Clausen, M., & Gow, A. J. (2017). Older Adults Perceptions of Technology and Barriers to Interacting with Tablet Computers: A Focus Group Study. Frontiers in Psychology, 8, 1687. https://doi.org/10.3389/fpsyg.2017.01687 Wand, A. P. F., Zhong, B.-L., Chiu, H. F. K., Draper, B., & De Leo, D. (2020). COVID-19: The implications for suicide in older adults. International Psychogeriatrics, 16. https://doi.org/10.1017/S1041610220000770 Weible, C. M., Nohrstedt, D., Cairney, P., Carter, D. P., Crow, D. A., Durnov, A. P., Heikkila, T., Ingold, K., McConnell, A., & Stone, D. (2020). COVID-19 and the policy sciences: Initial reactions and perspectives. Policy Sciences, 53(2), 225241. https://doi.org/10.1007/s11077-020-09381-4 Whitehead, B. R., & Torossian, E. (2021). Older Adults Experience of the COVID-19 Pandemic: A Mixed-Methods Analysis of Stresses and Joys. The Gerontologist, 61(1), 3647. https://doi.org/10.1093/geront/gnaa126 Wiley, L. F. (2020). Public health law and science in the community mitigation strategy for Covid-19. Journal of Law and the Biosciences, 7(1), lsaa019. https://doi.org/10.1093/jlb/lsaa019 Wosik, J., Fudim, M., Cameron, B., Gellad, Z. F., Cho, A., Phinney, D., Curtis, S., Roman, M., Poon, E. G., Ferranti, J., Katz, J. N., & Tcheng, J. (2020). Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association, 27(6), 957962. https://doi.org/10.1093/jamia/ocaa067 Wu, Y.-C., Chen, C.-S., & Chan, Y.-J. (2020). The outbreak of COVID-19: An overview. Journal of the Chinese Medical Association, 83(3), 217220. https://doi.org/10.1097/JCMA.0000000000000270 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 90 Wu, Y.-H., Ware, C., Damne, S., Kerherv, H., & Rigaud, A.-S. (2015). Bridging the digital divide in older adults: A study from an initiative to inform older adults about new technologies. Clinical Interventions in Aging, 193. https://doi.org/10.2147/CIA.S72399 Yamada, T., Chen, C.-C., Murata, C., Hirai, H., Ojima, T., Kondo, K., & Iii, J. (2015). Access Disparity and Health Inequality of the Elderly: Unmet Needs and Delayed Healthcare. International Journal of Environmental Research and Public Health, 12(2), 17451772. https://doi.org/10.3390/ijerph120201745 Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner, 36(6), 284289. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590951/ Zamanian, M., & Heydari, P. (2012). Readability of texts: State of the art. Theory and Practice in Language Studies, 2(1), 42-53. https://doi.org/10.4304/tpls.2.1.43-53 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 91 Table 1 Participant Characteristics Participan t ID Gender Age English Proficiency Cognitive and Psychological Competency Rural Community Dweller 71 Number of Medical conditions 4 130108 Female Yes Yes Yes 180503 Male 65 3 Yes Yes Yes 050820 Female 81 5 Yes Yes Yes 130419 Male 72 3 Yes Yes Yes 020218 Female 74 5 Yes Yes Yes 100619 Female 67 3 Yes Yes Yes 100319 Female 82 6 Yes Yes Yes 100713 Female 80 4 Yes Yes Yes 160919 Female 72 11 Yes Yes Yes 231008 Female 77 4 Yes Yes Yes RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 92 Table 2 Codebook Example Participant Quotations ID 231008 My motivation to be physically active has really been affected that I dont want to do nothing. I just want to lay around all the time and sleep, and I have to make myself get up and do stuff. Initial Broad Descriptions Languished. 050820 Missed family gatherings. Experienced loneliness. Became depressed. Feelings of being isolated from friends. Fear of missing out. 100619 020218 160919 I have a very large family and we got together once a month, all of us at our, my house. And theyd hardly be room to walk through the people and it abruptly stopped with this (COVID19 pandemic) its one of the most horrible experiences in my 81 years the depression of not being able to see your friends and to get out, um, puts a big wall between how do you pick yourself up, um, when you want to go and you can't get off, it's like the door is locked and I have to stay in here and everybody else is outside having a good time. Before I, I did it on my own. I went to the grocery store, like any other person went shopping, but when COVID come around, I stopped. I didn't go anywhere. I stayed at home. My family did my grocery shopping. I used to eat out a lot I like, um, amusement parks. I love roller coasters and I got my boyfriend to go to Kings Island with me. We even bought a year pass, our biggest thing we wanted to do before COVID hit and we didn't get to then, and now we're, we're waiting till we can, is going zip lining. So, I want to go zip lining COVID-19 really put a damper on that. Initial Theme Became passive and unmotivated during the pandemic. Changes in shopping habits. Recreational activities affected. Sub-Theme Physical Activities Socialization, Family Changes in lifestyle Before and During the COVID-19 Pandemic Friends Shopping Habits Recreation RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 93 Table 3 Codebook: Final Themes Initial Theme Changes in lifestyle Before and During the COVID-19 Pandemic Participant Quotations Initial Broad ID Descriptions 231008 My motivation to be physically active has really been Languished. affected that I dont want to do nothing. I just want to lay around all the time and sleep, and I have to make myself Became passive and unmotivated during get up and do stuff. the pandemic. 050820 I have a very large family and we got together once a Missed family month, all of us at our, my house. And theyd hardly be gatherings. room to walk through the people and it abruptly stopped Experienced with this (COVID-19 pandemic) its one of the most loneliness. horrible experiences in my 81 years Became depressed. 100619 the depression of not being able to see your friends Feelings of being and to get out, um, puts a big wall between how do you isolated from pick yourself up, um, when you want to go and you can't friends. Fear of missing out. get off, it's like the door is locked and I have to stay in here and everybody else is outside having a good time. 020218 Before I, I did it on my own. I went to the grocery store, Changes in shopping like any other person went shopping, but when COVID habits. come around, I stopped. I didn't go anywhere. I stayed at home. My family did my grocery shopping. 160919 I used to eat out a lot I like, um, amusement parks. Recreational I love roller coasters and I got my boyfriend to go to activities affected. Kings Island with me. We even bought a year pass, our biggest thing we wanted to do before COVID hit and we didn't get to then, and now we're, we're waiting till we can, is going zip lining. So, I want to go zip lining COVID-19 really put a damper on that. Sub-Theme Physical Activities Final Theme Socialization, Family Friends Shopping Habits Recreation Lifestyle Changes RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 94 Figure 1 Colaizzis Seven Steps Coding Process Phase 2 Phase 3 Phase 4 Phase 5 Coders Repeated Readings of Transcripts Codebook: Drawing out specific phrases, sentences statements, expressions, clauses, and sentences. Initial Broad Themes: Extracted phrases from phase two will be assigned broad descriptions that provide distinctive categories and characteristics. Narrowing initial broad themes into all-embracing final themes Final Themes: All embracing comprehensive descriptions Phase 6 Narrative Descriptions Phase 7 Second Member-Checking Repeat 1-3 for each participants transcript Phase 1 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Figure 2 Colaizzis Descriptive Phenomenological Analysis Method 95 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Figure 3 Example Perceived Theme Relationships Mitig a tio n Ma nd a te s a nd Pro to co ls Life sty le Cha ng e s: De cre a se d Phy sica l Activitie s Health and Wellbeing: Exacerbation of Chronic Medical Conditions Ne ce ssita te s Acce ss to He a lth Ca re Se rvice s Use o f Te chno lo g y Me e ting He a lth Ca re Ne e d s 96 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 97 Appendix A IRB Approval Human 800/232-8634 x5774 Sease Room 201L Indianapolis, IN 46227 Research Protections Program (HRPP) 1400 East Hanna Avenue http://irb.uindy.eduhr pp@uindy.edu 1 (317) 781-5774 March 10, 2021 NOTIFICATION OF EXEMPTION DETERMINATION Study Number: 01385 Study Title: Meeting Health Care Needs: The Perspective of Rural CommunityDwelling Older Adults with Multiple Chronic Diseases During the COVID-19 Pandemic Exemption Determination Date: March 10, 2021 Principal Investigator: Laura Santurri, PhD, MPH Director, Health Sciences Program The above-referenced protocol has been reviewed in accordance with the US Department of Health & Human Services (DHHS), Office for Human Research Protections (OHRP) regulations, specifically 45 CFR 46.104. Based on these criteria, this study is exempt from IRB Review. This exemption is valid unless changes in the project may impact the eligibility for exemption under the federal regulations. If you need to make any changes to the study, please contact the HRPP office hrpp@uindy.edu for guidance on whether additional review is required. Please submit all personnel changes through IRBManager as a Modification of Approved Protocol. Upon completion of your study, please submit a closure report through the IRBManager system. Yvonne Wakeford, Ph.D. Director: Human Research Protections Program (HRRP) HRPP Jan 2019 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 98 Appendix B Letter of Cooperation Romeo Acosta, PT, MHS Reid Home Health 2220 Chester Boulevard Richmond, IN 47374 (765) 960-0680 romeo_acosta@chihealthathome.com January 4, 2021 Gina Lucas, RN, BSN, COS-C, CRNI Associate Corporate Responsibility Officer Common Spirit Health at Home 1700 Edison Drive Milford, OH 45150 (513) 576-0262 Gina.lucas@chihealthathome.com Re: Research Study Permission Request Letter of Cooperation Dear Ms. Lucas, My name is Romeo Acosta. I am a full-time physical therapist at Reid Home Health in Richmond, a branch of Common Spirit Health at Home in Indiana. I am pursuing a doctoral degree in Health Science and in the process of initiating my research dissertation project. I am writing to you to ask for permission to conduct human subjects research involving our branch in Richmond, Indiana. This endeavor entails recruiting potential participants ages 65 and older from the patient roster of Reid Home Health. My research study will follow the University of Indianapolis Human Research Protection Program Institutional Review Board (HRPPIRB) guidelines. In addition, patients privacy and the confidentiality of medical records will be protected in accordance with the Health Information Portability and Accountability Act. In summary, my research project is a qualitative phenomenological study that aims to understand the lived experiences of rural community-dwelling older adults with multiple chronic diseases during the COVID-19 pandemic. Its primary focus is to determine how this population experienced health care during this time. The study involves an audio-recorded interview that will be transcribed and analyzed to extract deeper meaning and interpretations of the participants lived experiences. The results are anticipated to inform healthcare providers, educators, and policy makers of the necessary changes in policies and planning to ensure that rural community-dwelling adults healthcare needs will be met in the next health care crisis. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 99 I am conducting this research on my own without support or funding from any source. The University of Indianapolis HRPPIRB requires that any institutions involved in a research study, directly or indirectly, should be aware of the research being conducted within their jurisdiction. A letter of cooperation provides acknowledgment of cognizance and permission of the research study. I have attached the University of Indianapoliss letter of cooperation with my email. You may use the template per your choice and transfer it to the companys letterhead. Copies of my research project proposal and recruitment flyer are also included in the attachments. I am looking forward to your response. Please feel free to contact me by email or phone at any time for any queries. I thank you for your precious time and kind consideration. Sincerely, Romeo Acosta, PT, MHS RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Appendix C Approval of Letter of Cooperation 100 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 101 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Appendix D Recruitment Flyer 102 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 103 Appendix E Information Sheet Department of Interprofessional Health and Aging Studies, University of Indianapolis KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS You are being asked to participate in a research study about understanding rural communitydwelling older adults lived experiences during the COVID-19 pandemic related to health care needs and wellbeing. Your decision to participate is completely voluntary. This research project will include an audio-recorded interview that will take one to two hours of your time. About four weeks later, you will be asked to review, based on your preference, a print on paper or an emailed copy of the interview. Approximately four months after that, you will be asked to provide your feedback on the researchers interpretations of the information you provided. There are no anticipated risks or discomforts with this study. You have the right to choose to discontinue your participation at any time, and it will not be held against you if you do so. While there are no direct benefits to you for participation, it is anticipated that the study results may help health care professionals, educators, and policymakers address the needs of rural community-dwelling older adults like you during situations like the COVID-19 pandemic. CONSENT TO PARTICIPATE IN RESEARCH STUDY Meeting Health Care Needs: The Perspective of Rural Community-Dwelling Older Adults with Multiple Chronic Diseases During the COVID-19 Pandemic Study Principal Investigator (PI): Laura Santurri, PhD, MPH, CPH Uindy Email: santurril@uindy.edu Uindy Telephone: (800) 232-8634 x2409 Laura Santurri, PhD, MPH, CPH, and Romeo Acosta, PT, MHS in the Department of Interprofessional Health & Aging Studies at the University of Indianapolis (Uindy) are conducting a research study. You were selected as a possible participant in this study because you are 65 years or older, have two or more chronic conditions, live in a rural community, and communicates in the English language. Your participation in this research study is voluntary. Why is this study being done? This research study is about understanding rural community-dwelling older adults lived experiences during the COVID-19 pandemic related to meeting their health care needs. The results are anticipated to help healthcare professionals (doctors, nurses, insurance companies, therapists, and other medical professions), educators, and policymakers address the needs of rural community-dwelling older adults like you during situations similar to the COVID-19 pandemic. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 104 Participate in an audio-recorded interview that will take one to two hours of your time. The location of the interview will be of your choice, such as the comfort of your home. A virtual or phone interview will also be an option. Within a month of the interview, review a typed up or an email copy (based on your preference) of the audio recorded interview. At that time, you will have the opportunity to modify or add to your previous statements. Approximately four months after the interview, review and provide feedback on the researchers interpretations of the information you provided. How long will I be in the research study? Your participation in the research study will last approximately four months. This includes the initial interview, providing feedback on the typed up or email copy of the interview about one month after that, and then providing feedback on the researchers interpretations of the information you provided about four months after the interview. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts with this study. Are there any potential benefits if I participate? You will not directly benefit from your participation in this research study. However, it is anticipated that the results of the study may help health care professionals, educators, and policymakers address the needs of rural community-dwelling older adults like you during situations like the COVID-19 pandemic. Will I be paid for participating? As a token of appreciation for sharing your time in this research study, you will receive a $25 gift card. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. All study materials will be stored on a password-protected computer and database. Typed up copies of the interview and the researchers interpretations of the information you provide will not include any identifying information. Only the research study member who works for Reid Home Health will review your medical record. The medical record review will determine whether or not you will meet the inclusion RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 105 criteria for this research study. This research studys requirements are related to age, residents location, having two or more medical conditions, and ability to understand and speak English. None of the information during the medical review will be kept or reported. Will the data from my study be used in the future for other studies? Data from this study may be used for future research or shared with other researchers for studies without additional informed consent. However, none of your identifying information will be shared. What are my rights if I take part in this study? You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Withdrawal from the study will not affect the health care services provided to you by Reid Home Health Agency. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments or concerns about the research, you can talk to the one of the researchers. Please contact: Laura Santurri, PhD, MPH, CPH (317) 788-2409 or santurril@uindy.edu Romeo Acosta, PT, MHS (765) 969-5325 or acostar@uindy.edu The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. Follow up studies We may contact you again to request your participation in a follow up study. As always, your participation will be voluntary, and we will ask for your explicit consent to participate in any of the follow up studies. How do I indicate my informed consent to participate in this study? You do not need to sign this or any other document to indicate your consent. Completion of the interview shows that you are willing to participate. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 106 Appendix F Interview Guide I, Romeo Acosta, am a healthcare professional in the field of physical therapy. I want to extend my gratitude and appreciation for your willingness to participate in this interview. This interview is part of my doctoral research project in the Health Science program at the University of Indianapolis. The purpose of this research study is to understand the experiences of older people with multiple chronic illnesses during the COVID-19 pandemic. The results of this study will help those who plan and provide healthcare to prepare for ways to ensure that the healthcare needs of older adults like you will be met in the next healthcare crisis. During the interview, I will be asking questions about your social, recreational, physical fitness, entertainment, and health care management experiences during the COVID-19 pandemic. The interview may take approximately thirty to ninety minutes. Your stated responses to all the questions will be kept confidential. You have the right to decline to answer any particular questions and discontinue the interview at any time. I want to remind you that participation in this study is not connected to your health care and will not affect the health services you are receiving from Reid Home Health Care. Before we proceed, do you have any concerns and questions? As mentioned previously, I will be audio recording the interview to capture your responses. Are you okay with me starting the audio recording now? Questions RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 107 To begin the interview, please tell me about your life before and during the COVID-19 pandemic. 1. Describe your shopping habits, such as grocery, department store, and accessory shopping, before and during the COVID-19 pandemic. 2. How was your social life before and during the COVID-19 pandemic? 3. What were the sources of your entertainment and recreational activities before and during the COVID-19 pandemic? 4. Describe your physical fitness activities before and during the COVID-19 pandemic. 5. How did you meet your health care needs, such as doctor's appointments, medical tests, prescribed medications, and other medical necessities, if any (physical therapy, vision, podiatry, dental, etc.), before and during the COVID-19 pandemic? Now, I will ask you about the impact of the COVID 19 pandemic on your life. 6. What part of your life has had the most significant change directly caused by the COVID19 pandemic? a. In what ways has this part of your life changed? 7. What part or parts of your life were not affected by the COVID-19 pandemic? The next questions will be related to the effects of the CDC's stay-at-home order and mitigation protocol, including physical distancing (keeping six feet apart), avoid gatherings that do not allow for physical distancing, and mask-wearing during the pandemic. 8. How do you believe that the stay-at-home order and mitigation protocol affected your attitude and outlook in life? 9. How did the stay-at-home order and mitigation protocol make you feel? a. Explain why you felt that way. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 108 10. Based on your answer in question four, how did the stay-at-home order and mitigation protocol make you feel about its effect on your physical fitness habits, such as exercising in the gym, walking alone or with friends, etc.? 11. To what extent do you believe that the effect of the stay-at-home order and mitigation protocol on your attitude and outlook in life and the effect of the stay-at-home order and mitigation protocol in your motivation in health and fitness activities are interconnected? Now, I will be focusing on experiences concerning your health care needs while the COVID-19 pandemic is happening. 12. Can you talk about changes that occurred in meeting your health care needs during the pandemic, including medical appointments, getting your prescriptions, home health services, communicating health-related concerns, and medical emergencies (if any)? 13. If there were no changes that occurred in meeting your health care needs during the pandemic, can you describe how you were able to maintain your ability to keep up with your health care needs under the mitigation mandate? 14. What changes in trying to meet your health care needs challenged you the most? a. How have these changes most challenging to you? b. How did these changes affect your ability to manage your health issues? 15. If you had any specific health issue (medical diagnosis) affected the most by the COVID19 pandemic, explain why you believe so? 16. How have you adjusted to and dealt with the changes and challenges you have faced in meeting your health care needs? RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 109 17. If any of the changes made meeting and managing your health care needs easier, what are these changes, and in what way did these changes helped meeting your health care needs easier? If you experienced telehealth during the COVID-19 pandemic, I have some specific questions about it. 18. Describe your experience if you participated in video conferencing and or phone calls to access and receive health care services? 19. If you did not participate in video conferencing and or phone calls, how did you access and receive health care services? 20. If you participated in using telehealth for monitoring your vital signs, describe your experience in taking your vital signs, entering them on a digital device, and sending the information to your healthcare provider? 21. If you did not use digital technology to monitor your vital signs, how did you communicate your vital signs issues to your healthcare provider? 22. If there is anything you feel could make the use of telehealth easier and more effective in managing your health care needs, what would it be, and why do you believe so? I want to conclude our interview with your comments, recommendations, and suggestions. 23. Based on what you experienced living through the COVID-19 pandemic, what recommendations or suggestions would you have related to how health care services could be better or best delivered to rural, older people like you? 24. What advice would you have on how healthcare professionals could better help people like you manage their health care in a pandemic? 25. What other suggestions do you want to share? RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 110 Before I end this interview, I am happy to answer any questions you may have. If you have no questions, I would like to remind you that I will be sending you copies of our interview transcripts for your review. You should expect the transcripts in two weeks. I will also send you copies of my interpretations of your shared lived experiences in approximately three months. You are welcome to make changes you feel are necessary to describe your lived experiences accurately. Thank you so much for your precious time, kind consideration, and thoughtful responses. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 111 Appendix G First Member-Checking Letter of Instructions Dear Mrs./Mr., First, I would like to thank you again for participating in my study. As we discussed, a copy of our interview transcript is included with this letter. Review the transcript, and feel free to make changes, corrections, and additional comments to the transcript itself. Please write your changes, revisions, and other suggestions exactly where you want them to be in the transcript. I will be calling you in a week or two to ask if you have made changes to the transcript. If you answered yes, then I will schedule a time when I can pick up the transcript. If you did not make any changes, then we do not have to do anything else. I anticipate that in about three to four months, I will be able to complete the analysis of the shared experiences of all my participants and come up with the results. I will send you a copy of the analysis results of all the participants' interviews, and you are welcome to give your comments, recommendations, and suggestions. Please, do not hesitate to call me at (765) 969-5325 or email me at acostar@uindy.edu for any questions you may have. Sincerely Yours, Romeo Acosta, PT, MHS 3517 Waterford Street, Richmond, IN 47374 (765) 969-5325 RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 112 Appendix H Narrative Description of Final Themes Based on their shared lived experiences through interviews, the community-dwelling older adults (CDOA) participants in this study were presented with new challenges from the COVID-19 pandemic related to meeting their health care needs. However, the participants showed resiliency, resourcefulness, perseverance, adaptation, and reliance on faith to overcome the barriers imposed by the COVID-19 pandemic. The CDOA in this study considered the impact of mitigation protocol on lifestyle, health and wellbeing, access to health care services, and the influence of technology to be the most critical factors that affect the ability to meet their health care needs. The participants' disclosed lived experiences associated with addressing their health care needs during the COVID-19 pandemic showed interconnections of these factors, i.e., how the influence of technology affects access to health care services, lifestyle, and health and wellbeing; how the mitigation protocols promote the use of technology to access health care services, affected lifestyle, and health and wellbeing of the participants. The participants were asked for recommendations to help healthcare providers, politicians, and educators address and meet their health care needs effectively in the next pandemic. Impact of the Mitigation Mandate and Protocol in Lifestyle, Health, and Wellbeing In general, the participants' shared lived experiences suggested that the stay-at-home mandate, social distancing, and mask-wearing caused significant changes in their lifestyle during the pandemic. Routine activities such as walking the dog, walking with friends at the park, attending church, club activities, working out in the gym, family gatherings, shopping, and eating out with RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 113 friends and family are all put on hold. The participants' reflections suggested that these changes adversely impacted their medical, mental, and physical condition. Participants pointed out that isolation made them feel abandoned and alone, which led to depression. Also, some participants viewed social distancing, stay-at-home, and mask-wearing infringed on their freedom to do usual activities. Participants expressed that mitigation protocols made it difficult to access health care services and increased their mental stress. Some participants believed mask-wearing caused or aggravated respiratory illnesses. However, others feel it was a necessary practice to prevent the spread of COVID-19 infection. The shutdown of specific medical departments such as elective surgery forced some of the participants to have delays in joint replacements and spine surgeries. Such unanticipated holdback resulted in an extended period of living with pain. However, all participants expressed an optimistic outlook of their health situation and life overall. Coping mechanisms were employed to overcome medical, psychological, and physical deterioration. Participants turned to humor and laughter from any source (TV shows, newspapers, radio, conversations, streaming video shows on the phone) to combat loneliness. Some wrote greeting cards and letters of encouragement to friends and church members to feel useful. Others noted increasing their telephone use to reach out to friends and family members to fill out the time. Some participants walked in their neighborhood and interacted with neighbors to stay physically active and emotionally and mentally engaged but were also observant of the mitigation protocols. House and yard work kept the other participants busy. Access to Health Care Services The participants' shared lived experiences elicited common concerns and needs related to accessing health care services during the pandemic. These issues are about health care needs, RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 114 transportation, appointments, pharmacology, interventions, treatment, and support system. Taken as a whole, the accounts of the participants showed interdependence of these issues. Technology and the mitigation protocol also impacted CDOA's ability to access health care services. Transportation Participants cited transportation as one of the main concerns related to accessing health care during the pandemic because of the impact of the mitigation protocol. Participants who could not drive even before the pandemic and those who otherwise could drive but due to age-related issues, chronic medical problems, and recent surgical interventions expressed worry due to the uncertainty of not finding anyone to drive them to health-related appointments. However, despite the mitigation protocol, all participants were able to access transportation to appointments, pharmacies, grocery stores, and department stores like before the pandemic. Participants stated that public transportation continued to operate. Also, private services, friends, and family members were available to help them with transportation. All of the support systems mentioned were able to provide services by strictly following the mitigation protocol. Appointments All participants reported experiencing some degree of difficulty and reservation with keeping and attending medical appointments. Most of them made necessary adjustments and arrangements to keep up with medical appointments during the pandemic, but some hold off in seeking medical consultation. The main reason for declining medical consultation is fear of being admitted to the hospital or nursing home where chances of acquiring COVID-19 infection are more significant since it is full of people infected by COVID-19. The promotion of technology (remote visit), the mitigation protocols, and transportation capability (mentioned above) are three factors that influenced the participants' motivation and RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 115 ability to attend appointments. Some participants deemed the use of remote visits (video or teleconferencing) helpful, convenient, appropriate, allowing for immediate access to care, and safer than in-person appointments. Some expressed frustration but complied with the mitigation mandate and protocols for in-person appointments (mask-wearing, waiting in the car, social distancing). Others resisted and objected to their use, believed that remote visits do not allow healthcare providers to see nuances such as mental stress, and strongly voiced their preference for face-to-face appointments. One participant experienced punctuality instead of the usual long waiting time from the scheduled appointments before the pandemic. Others had trouble scheduling appointments, including with specialized healthcare providers, during the "lockdown." Pharmacology In general, the participants experienced no disruption in receiving prescribed medications either by store pick-up or through the mail. Similar to transportation and appointments, most of the participants in this study depended on support systems available to secure needed medicines. One participant cited that one of the values of receiving nursing services at home (home health care), especially during the COVID-19 pandemic, was their ability to facilitate prescription medication management. Through their assessment each visit, home health nurses could ascertain the need for prescription adjustments or new medications. The nurses communicate these recommendations to the attending physician, which helped eliminate the possibility of the participants being scheduled for an in-person consultation, reducing the exposure to COVID-19. Others expressed frustration that some medications could not be acquired through the mail system. Interventions and Treatment RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 116 The interventions and treatment mentioned by the participants in this study were generally related to prescribed medications, declining physical condition (muscular weakness, decreasing endurance, joint stiffness, joint pain, muscular aches, standing balance deterioration), chronic disease management such as arthritis (knees and back), blood pressure, and gastrointestinal problem. Similar to general medical appointments, everyone experienced varying degrees of difficulty scheduling needed medical interventions and treatments. Most of the participants continued to schedule and kept appointments for interventions and treatments for joint problems, dental, eyes, and medical conditions. Three participants received elective surgeries (two joint replacements and one spine surgery), and all experienced delays in surgical interventions due to the "lockdown" mandate. One of the two joint replacement participants expressed disappointment for being unexpectedly discharged on the same day, while the other experienced delays in needed health-related interventions. The participant with the shoulder problem opted out due to fear of acquiring COVID-19 in the hospital. One of the participants, a veteran, continues to receive treatments at the local and out-of-state veterans administration facilities. The same participant expressed disappointment and frustration from the delay and limited rehabilitation treatment while in the nursing home. Another participant who received in-clinic hemodialysis experienced alteration of the procedure (COVID19 mitigation protocol and not allowed to bring food), but the scheduled treatment continued uninterrupted. All participants voiced appreciation for receiving interventions and treatment for their medical issues and mobility problems related to balance, strength, endurance, and coordination from the home health care program. The participants deemed home health care invaluable during the pandemic because it could prevent health issues from worsening by serving as a bridge between RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 117 the patient and the primary care physician. It lessened the mental stress of calling the physician and being scheduled for an appointment under the mitigation mandate. Also, the routine inperson visitations of the home health care agency's clinicians provided psychosocial support to the participants. The participants remarked not experiencing problems in general with pharmacological interventions, which continued to be received by mail or store pick up. Support System The participants clearly expressed the significance and value of the support system in facilitating access to services to meet their health care needs. The support system received came from family, friends, church members, club members, home health care clinicians, and the local community groups and services. It impacted all the facets of participants' health and wellbeing. Friends and members of the participants' families, church, clubs, and community groups helped with transportation (medical appointments and picking up prescriptions), shopping (groceries, clothing), meals (preparation and deliveries), home maintenance, and financial organization. The home health care services provided immediate intervention and treatment of medical problems, activities of daily living, and mobility issues related to strength, endurance, balance, and coordination. Influence of Technology The stay-at-home mandate and mitigation protocols promoted the use of technology to facilitate health care access and delivery. The CDOA participants in this study have mixed sentiments regarding the use of technology during the pandemic. Some participants believed that technology has a place in health care, but others felt it is a waste of time and money, worthless, silly, and a con. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 118 Positive perspectives in the utilization of technology during the pandemic include convenience (do not have to leave home and be out in public), immediate access to healthcare providers, a sense that someone is listening, digital therapeutics (digital blood glucose level monitoring), a source of coping mechanism (entertainment, hobbies, social networking), meal ordering, prescription refill, and online shopping. Negative views shared are awkwardness (do not have the comfort of face-to-face interactions), loss of valuable non-verbal communication (body language and gestures), expensive, complicated, limited to verbal communication (do not include vital signs and lab work), and cannot substitute for physical therapy interventions and treatment. The shared lived experiences of the participants suggested the utilization of technology was not only for health care access and delivery but also for personal needs such as shopping, meal deliveries, and entertainment. Overall, based on the prevailing opinion of the participants, the challenges to the acceptance of technology as an effective tool for meeting the participants' health care needs depend on affordability, ease of use, and purpose. Participants' Recommendations for Meeting CDOAs Health Care Needs in the Next Pandemic When asked for recommendations on how healthcare could be better or best delivered to their demographics during the pandemic, the participants provided suggestions covering politics, freedom of choice, finances, transportation, technology, local community program, healthcare professionals, and home health care. Comments regarding politics are related to openness, transparency, and honesty. The consensus is that doctors should be leading the dissemination of information and guidance and not the politicians. Some participants emphasized freedom of choice regarding mask-wearing, stay-at-home, social distancing, and vaccination mandate. Preparedness is also stressed. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 119 Collectively, participants concerns and suggestions related to financing (cost), local communitybased health care program, transportation, and technology emphasized the interconnectedness of the four issues. Affordability is one barrier that prohibits participants from getting transportation to medical appointments, picking up prescriptions, and shopping for essentials. The cost of digital devices such as smartphones, tablets, or computers and internet connections also prevents most participants from participating in telehealth. Therefore, the participants recommend financial assistance for transportation and digital devices to access health care services. Some advocated for the establishment of a free transportation program in their local community. In addition to transportation, participants also made other local community program recommendations such as proactive, targeted campaigns and advertisements for CDOA on COVID-19 information updates (mortality and spread of infection rate, the emergence of new variants, vaccination availability, and changes mitigation mandates) and building town clinic. Related to telehealth (technology), participants also suggested incorporating vital signs during videoconferences (remote video visits). Furthermore, the participants endorsed an older adultfriendly educational and training program in using digital devices to access health care services. Participants advised healthcare providers to listen carefully, proactively reach out, and make house calls (physicians). The participants who voiced disfavor for remote visits advocated keeping face-to-face appointments. A common sentiment by the participants is related to the value of home health care in meeting their health care needs during the pandemic. All participants proposed that home health care services should be extended and provided without delay during a pandemic. Lastly, the participants' general advice, to ensure that the health care needs of CDOA like them are addressed and met, is to be informed, cooperative, and follow the rules. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE 120 Appendix I Second Member-Checking Instructions Dear Mr./Mrs. Greetings! This is Romeo Acosta, the physical therapist from Reid Home Health, who asked for your participation in my research project earlier this year. I hope that this letter reaches you in good health and wellbeing. As we have discussed, I am to send you the summary of my study's results for your review. A copy is included with this letter. Please read it carefully at your convenience. You will receive a phone call from me after a few days to ask for your responses. Similar to the transcripts I emailed you a couple of weeks after the interview, you are welcome to make revisions or comments on these documents. If you have remarks or other opinions, please use the "track and change" option in Word Doc for typing your changes next to the section where you want them included. Email back the document when you complete all your revisions. If you do not have any changes, then you do not have to do anything. Please remember that this is just part (last part) of the data analysis process. Once I receive your responses, then I will start writing my research project study manuscript. I aim to have it completed by the middle of November and defend it successfully by December of this year to earn my doctorate in Health Science. I want to take this opportunity to give you once again my deepest gratitude for sharing your precious time. Without your participation, this endeavor will not have been possible. Also, the meaning of your shared lived experiences may help inform healthcare providers, policymakers, and educators to become better prepared in helping rural community-dwelling older adults like you meet their health care needs in the next pandemic. RURAL COMMUNITY-DWELLING OLDER ADULTS PERSPECTIVE Sincerely Yours, Romeo Acosta, PT, MHS 3517 Waterford Street, Richmond, IN 47374 (765) 969-5325 121 ...